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Treatment compliance and early termination of therapy: a comparative study.

BACKGROUND: Compliance in therapy appears to be linked to the process of therapeutic alliance. A positive patient-therapist relationship usually leads to successful completion of therapy. The aim of this study was to compare evidence, collected at two time periods in a Community Mental Health Center in Athens, on factors affecting treatment compliance. The hypothesis was that by modifying the therapeutic team's functioning, noncompliance could be reduced. METHODS: Epidemiological data were collected from child and adolescent out-patient files at two time periods: time period A, 1990-1994, n = 455 (sample A) and time period B, 2000-2002, n = 476 (sample B). Variables pertaining to the patient, his family and recommended treatment were examined. Student's t test and the Pearson chi2 test were used in order to explore the correlation of the variables with treatment completion in each sample. Logistic regression analyses were used to determine whether the effect of each variable on treatment completion differed between the two samples. RESULTS: In sample A, most patients (58.6%) did not comply with therapy. The type of recommended treatment, the number of sessions, season of admission and the type of presented problem were found to correlate with treatment completion. Between the two time periods, certain modifications were implemented in the team's functioning (less diagnostic sessions, focused psychotherapy techniques, less time interval between referral and first diagnostic appointment). A significant reduction in the early termination rate (45.7%) was noted in sample B. The type of recommended treatment, the number of sessions, the family's situation, the mother's educational level and the patient's gender were related to treatment completion in sample B. The effect of the type of proposed treatment and the mean number of sessions of the completed treatments differed significantly between the two samples. CONCLUSIONS: Early termination rates in therapy decreased between two time periods. This decrease may be attributed to modifications in the team's functioning, aimed at improving the therapeutic relationship. The limitation of this study is that only those factors pertaining to the service's organization and functioning were investigated.

Child↗

A comparative study of two levonorgestrel-containing hormone replacement therapy regimens of efficacy and tolerability variables.

OBJECTIVE: To compare the effect of two sequential hormone replacement regimens differing in the dose of levonorgestrel on climacteric symptoms, bleeding pattern and lipid metabolism in postmenopausal women. STUDY DESIGN: In a multicentre, randomized, double-blind, active-treatment-controlled study, 210 postmenopausal women were assessed at the end of treatment cycles 3 and 6. The high-levonorgestrel group was treated with 2 mg estradiol valerate (days 1-21) sequentially combined with 0.25 mg levonorgestrel (days 12-21). The low-levonorgestrel group received the same estrogen regimen (2 mg estradiol valerate, days 1-21), but levonorgestrel was administered sequentially in a dose of 0.15 mg during the last 12 days of the cycle (days 10-21). Statistical analysis by Student's t-test for dependent variables (measured values versus baseline) and independent variables (differences between groups), and the composite t-test method for comparison of both regimens with respect to efficacy, was performed. RESULTS: Both groups were statistically comparable. The trial was completed by 137 subjects. Protocol violations occurred in 38 cases. Thirty-five subjects dropped out during the study, 21 of them because of adverse events. Both treatments were equally effective in the treatment of climacteric complaints. There were no clinically significant changes in body weight, blood pressure, haematological tests, and parameters of clinical chemistry. There was a tendency towards a reduction in bleeding intensity in both groups in the second half of the treatment period. The treatment for six cycles with both regimens significantly (P < 0.05) decreased plasma concentrations of triglycerides (significant in the low-levonorgestrel group only), high-density lipoprotein cholesterol, high-density lipoprotein-3-cholesterol, lipoprotein(a) and apolipoprotein A1. In parallel, the serum concentration of total cholesterol increased significantly in both treatment groups, whereas low-density lipoprotein cholesterol increased significantly in the high-levonorgestrel group only. The changes in high-density lipoprotein-2-cholesterol, and apolipoprotein B did not reach statistical significance. CONCLUSIONS: It can be concluded that both sequential combined oral hormone replacement therapy (HRT) regimens were equivalent with respect to efficacy and tolerability in the treatment of women with climacteric complaints. The preparation with the lower dose of progestin showed a tendency towards a less unfavourable influence on the lipid profile.

Cohort Studies↗

[Failure effects and gender differences in perfectionism].

Perfectionism is a dimension which has been studied very little as a separate entity. It is not even considered as a nosological factor. No classification of the medical sciences underlines its importance other than to speak of a personality trait, of an aspect, or of a parameter. Nevertheless, perfectionism is related to multiple disorders such as depression (18, 20, 36), suicide (8, 16, 55), nutritional problems (11, 28), anxiety (3), obsessive-compulsive personality disorder (53), social phobia (2), as well as insomnia (46). Certain authors stress the possible role of perfectionism in the development or the persistence of a substantial number of these disorders (7, 22, 38). Given these facts, it is all the easier to understand the interest shown by clinicians and researchers in the subject. Better detection and evaluation of its impact on behaviour is important in putting therapies in place (6, 53). Relationships between perfectionism and fear of failure have been approached (21, 51, 54). Correlations between perfectionism and high levels of state and trait anxiety have been demonstrated (23). The evaluation of perfectionism has been dealt with very little. Some questionnaires devote a sub-category to it, such as the Eating Disorder Inventory and the Irrational Beliefs Test. However, recently, it has been recognized that perfectionism is a multidimensional construct. Two Multidimensional Perfectionism Scales have been developed and investigated in relative isolation. Frost, Marten, Lahart and Rosenblate defined perfectionism as the setting of excessively high standards for performance associated with critical self-evaluation. Six dimensions are described: concern over making mistakes, high personal standards, parental expectations, parental criticism, doubt about quality of performance and organization. Internal consistency and validity have been established (25, 26). Hewitt and Flett (30, 31, 33, 35) have developed another approach where three dimensions of perfectionism are described: SOP (Self Oriented Perfectionism) related to high standards and self criticism, SPP (Socially Prescribed Perfectionism) related to the need of approval from others and fear of negative evaluation, OOP (Other-Oriented Perfectionism) reflecting a tendency to set high expectations for others and to evaluate them in a demanding way; this component is related, especially for males, to self-esteem, hostility and authoritarianism. Validity and internal consistency have been established too (30, 31, 35). The Frost and al's Multidimensional Perfectionism Scale and the Hewitt and Flett's scales are closely associated, except concerning the OOP. Because this component could provide new information, we have chosen the second scale, referring to the French translation and validation of Labrecque (45). EMP is the French name of MPS; it is a self-report questionnaire of 45 questions, in fact three subscales of 15 items rated on a 7-point Likert-type scale. MPS was administered to 617 first year students at the university of Liège (table II). Differences are considered according to gender and experience of failure i.e. the fact of repeating an academic year. We realized a component analysis with promax rotation. Among the different possibilities offered by the scree-test the choice of a 4 factor solution stresses the original structure: SOP (14 items), SPP (12 items), OOP (9 items) and anti OOP (10 items); the last one is additional but allows for respecting semantics and saturation of the items. The first aim of confirming validity and internal consistency is satisfactory. In other respects the multidimensional structure of the concept leads to consideration of a positive, adaptive perfectionism and a more negative perfectionism, facilitating psychopathology (59, 60, 61). So it seems interesting to compare the different components of MPS in order to find an eventual sex-failure effect. The evaluation of perfectionism is obvious, considering it as a personality trait, but it can be used also in taking into account stress and its impact, for instance that of academic performance (29, 37, 39, 58). Conferring on MPS more pertinence in gender differentiation and failure evaluation is an other goal of this research. Through the particular choice of statistical results, sex and sex-failure effects can be demonstrated: a MANOVA underlines sex effect (lambda de Wilks = 0.96, p = 0.001) and sex-failure effect (lambda de Wilks = 0.98, p = 0.05). Structure of MPS is different in four groups (FE: women with failure, FnE: women without failure, ME: men with failure, MnE: men without failure). ANOVA show differences of MPS3, MPS1 and MPS2. Far more promising is the use of LISREL method allowing for the construction of a coherent model of relationships between some dimensions of MPS and Test-Anxiety, approached here with THEE (test d'habileté aux études et à leur évaluation) French abbreviated version (49) of TASTE (Test for Ability to Study and Evaluation). In fact according to the literature of fear of failure, girls score higher on anxiety and procrastination but less on self-confidence. The structural model shows different pathways, more especially between SPP (socially prescribed perfectionism), T2 (sense of incompetence) and T1 (anxiety). SOP (self oriented perfectionism) and SPP (socially prescribed perfectionism) by girls are very much correlated; it seems that they are more subjected to society and its exigencies of studying but consequently they are more at risk of anxiety and a sense of incompetence. SOP (self oriented perfectionism) by boys functions more indiscriminately of SPP (socially prescribed perfectionism) and is negatively correlated with self-incompetence; boys are more self-confident but they usually procrastinate more probably because failure expectancies would be particularly harmful for their self-esteem; consequently, failure should be related to something else than their own capacity; this may be an explanation of the high rate of male dropouts and failure in the first year at the university of Liège; also a factor explaining the female domination at the university. In the same way the first choice of studies is moving towards shorter and less difficult orientation (46). In case of failure the model is very similar according to gender: SOP (self oriented perfectionism) and T1 (anxiety) are directly connected; SOP and SPP are in this case better correlated by boys but the path between SPP, sense of incompetence and anxiety is less significant than in girls. In conclusion, providing some modifications according to semantics, the choice of a four factor solution allows for confirmation of the original structure of MPS and for internal consistency. The different components of MPS vary according to gender: SOP and more OOP discriminate men and women; SPP allows for differentiating women with failure. A structural model enhances the role of perfectionism in the cognitive and behavioural contexts; for instance it clarifies its action on fear of failure and success rates according to gender.

Adult↗