Effect of counselling on the psychiatric morbidity associated with mastectomy.

A controlled trial was conducted to determine whether counselling by a specialist nurse prevented the psychiatric morbidity associated with mastectomy and breast cancer. Seventy-five patients were counselled by the nurse and monitored during follow-up, while 77 patients received only the care normally given by the surgical unit. Counselling failed to prevent morbidity, but the nurse''s regular monitoring of the women''s progress led her to recognise and refer 76% of those who needed psychiatric help. Only 15% of the control group whose condition warranted help were recognised and referred. Consequently, 12 to 18 months after mastectomy there was much less psychiatric morbidity in the counselled group (12%) than in the control group (39%). These findings highlight the high degree of psychiatric morbidity in patients who have undergone mastectomy and indicate the need to find ways of reducing this morbidity.     

Psychological outcomes of different treatment policies in women with early breast cancer outside a clinical trial.

OBJECTIVES--To assess outside a clinical trial the psychological outcome of different treatment policies in women with early breast cancer who underwent either mastectomy or breast conservation surgery depending on the surgeon''s opinion or the patient''s choice. To determine whether the extent of psychiatric morbidity reported in women who underwent breast conservation surgery was associated with their participation in a randomised clinical trial. DESIGN--Prospective, multicentre study capitalising on individual and motivational differences among patients and the different management policies among surgeons for treating patients with early breast cancer. SETTING--12 District general hospitals, three London teaching hospitals, and four private hospitals. PATIENTS--269 Women under 75 with a probable diagnosis of stage I or II breast cancer who were referred to 22 different surgeons. INTERVENTIONS--Surgery and radiotherapy or adjuvant chemotherapy, or both, depending on the individual surgeon''s stated preferences for managing early breast cancer. MAIN OUTCOME MEASURES--Anxiety and depression as assessed by standard methods two weeks, three months, and 12 months after surgery. RESULTS--Of the 269 women, 31 were treated by surgeons who favoured mastectomy, 120 by surgeons who favoured breast conservation, and 118 by surgeons who offered a choice of treatment. Sixty two of the women treated by surgeons who offered a choice were eligible to choose their surgery, and 43 of these chose breast conserving surgery. The incidences of anxiety, depression, and sexual dysfunction were high in all treatment groups. There were no significant differences in the incidences of anxiety and depression between women who underwent mastectomy and those who underwent lumpectomy. A significant effect of surgeon type on the incidence of depression was observed, with patients treated by surgeons who offered a choice showing less depression than those treated by other surgeons (p = 0.06). There was no significant difference in psychiatric morbidity between women treated by surgeons who offered a choice who were eligible to choose their treatment and those in the same group who were not able to choose. Most of the women (159/244) gave fear of cancer as their primary fear rather than fear of losing a breast. The overall incidences of psychiatric morbidity in women who underwent mastectomy and those who underwent lumpectomy were similar to those found in the Cancer Research Campaign breast conservation study. At 12 months 28% of women who underwent mastectomy in the present study were anxious compared with 26% in the earlier study, and 27% of women in the present study who underwent lumpectomy were anxious compared with 31% in the earlier study. In both the present and earlier study 21% of women who underwent mastectomy were depressed, and 19% of women who underwent lumpectomy in the present study were depressed compared with 27% in the earlier study.) CONCLUSIONS--There is still no evidence that women with early breast cancer who undergo breast conservation surgery have less psychiatric morbidity after treatment than those who undergo mastectomy. Women who surrender autonomy for decision making by agreeing to participate in randomised clinical trials do not experience any different psychological, sexual, or social problems from those women who are treated for breast cancer outside a clinical trial.     

Onset of adolescent eating disorders: population based cohort study over 3 years

ObjectiveTo study the predictors of new eating disorders in an adolescent cohort.DesignCohort study over 3 years with six waves.SubjectsStudents, initially aged 14-15 years, from 44 secondary schools in the state of Victoria, Australia.ResultsAt the start of the study, 3.3% (29/888) of female subjects and 0.3% (2/811) of male subjects had partial syndromes of eating disorders. The rate of development of new eating disorder per 1000 person years of observation was 21.8 in female subjects and 6.0 in male subjects. Female subjects who dieted at a severe level were 18 times more likely to develop an eating disorder than those who did not diet, and female subjects who dieted at a moderate level were five times more likely to develop an eating disorder than those who did not diet. Psychiatric morbidity predicted the onset of eating disorder independently of dieting status so that those subjects in the highest morbidity category had an almost sevenfold increased risk of developing an eating disorder. After adjustment for earlier dieting and psychiatric morbidity, body mass index, extent of exercise, and sex were not predictive of new eating disorders.ConclusionsDieting is the most important predictor of new eating disorders. Differences in the incidence of eating disorders between sexes were largely accounted for by the high rates of earlier dieting and psychiatric morbidity in the female subjects. In adolescents, controlling weight by exercise rather than diet restriction seems to carry less risk of development of eating disorders.

Key messages

• Adolescent females who diet at a severe level are 18 times more likely to develop an eating disorder than those who do not diet, and those who diet at a moderate level are five times more likely to develop an eating disorder
• High levels of psychiatric morbidity in females increase the risk of developing eating disorders by sevenfold
• Around two thirds of new cases of eating disorder arise in females who have dieted moderately
• The predominance of eating disorders in females is largely explained by the higher rates of earlier dieting and psychiatric morbidity
• Daily exercise seems to be a less risky strategy for controlling weight in adolescents

     

Support after perinatal death: a study of support and counselling after perinatal bereavement.

After an earlier study into the practical aspects of the management of perinatal death, a counselling service was introduced for parents whose baby had died in the perinatal period. The service was monitored, and the parents who received the service were compared with a group that did not. Fifty families were allocated randomly either to the counselling (supported) group or to the contrast group, who received routine hospital care. Assessment was carried out at six and 14 months after the death, using a semi-structured interview and two self-rating scales (the general health questionnaire and the Leeds scales). Two of 16 mothers in the supported group showed psychiatric disorder at six months, compared with 10 of 19 in the contrast group (p less than 0.01, Fisher''s exact test). There was no significant difference between the two groups at 14 months, when 80% of all the women studied had recovered psychiatric symptoms. Socially isolated women and those who marital relations lacked intimacy had a higher incidence of psychiatric symptoms at six months. Early pregnancy (within six months) was associated with a higher incidence of psychiatric symptoms in the unsupported group. The duration of bereavement reaction after perinatal death was appreciably shortened by support and counselling.     

Identifying and treating pregnant patients at risk from alcohol.

Heavy alcohol consumption during pregnancy has been associated with retardation of fetal growth and abnormal fetal development. Pregnant women whose offspring are at risk because of alcohol abuse can be identified and counselled by health professional providing prenatal care. Offspring born to women who had been drinking heavily and subsequently abstained from or reduced their intake of alcohol before the third trimester demonstrated improvements in growth and in regulation of sleep-awake states. The existing health care delivery system can be modified in a cost-effective manner to treat pregnant women who are problem drinkers. Physicians'' attitudes and behaviour are critical for the success of this strategy.     

Psychiatric Illness in General Practice: A Detailed Study Using a New Method of Case Identification

A self-administered questionary (the General Health Questionnaire) aimed at detecting current psychiatric disturbance was given to 553 consecutive attenders to a general practitioner''s surgery. A sample of 200 of these patients was given an independent assessment of their mental state by a psychiatrist using a standardized psychiatric interview. Over 90% of the patients were correctly classified as “well” or “ill” by the questionary, and the correlation between questionary score and the clinical assessment of severity of disturbance was found to be +0·80.The “conspicuous psychiatric morbidity” of a suburban general practice assessed by a general practitioner who was himself a psychiatrist and validated against independent psychiatric assessment was found to be 20%. “Hidden psychiatric morbidity” was found to account for one-third of all disturbed patients. These patients were similar to patients with “conspicuous illnesses” in terms both of degree of disturbance and the course of their illnesses at six-month follow-up, but were distinguished by their attitude to their illness and by usually presenting a physical symptom to the general practitioner.When 87 patients who had been assessed as psychiatric cases at the index consultation were called back for follow-up six months later, two-thirds of them were functioning in the normal range. Frequency of attendance at the surgery in the six months following index consultation was found to have only a modest relationship to severity of psychiatric disturbance.It is argued that minor affective illnesses and physical complaints often accompany each other and usually have a good prognosis.     

Relationship of Psychiatric Diagnosis and Weight Loss Maintenance in Obese Breast Cancer Survivors

Objective: Obese breast cancer survivors are a unique population for weight loss counseling because both obesity and a diagnosis of breast cancer can increase the risk of depression. In this pilot study, weight loss maintenance was examined in obese breast cancer survivors with relationship to psychiatric diagnosis. Research Methods and Procedures: Forty‐eight subjects were enrolled. The intervention, which used individualized counseling for diet and exercise, lasted 24 months. After a 6‐month period of no contact with study subjects, a follow‐up body weight was obtained at 30 months. Results: The nine subjects who dropped out of the study before 12 months all failed to complete a structured psychiatric interview. Of the remaining 39 subjects, 9 had major depressive disorder, and 10 had a definable psychiatric disorder of lesser severity such as adjustment disorder. Subjects with any type of psychiatric diagnosis displayed significantly less weight loss at the 12‐month time‐point than those with no diagnosis (6.3% vs. 12.6% loss of baseline weight, respectively). At the 30‐month follow‐up visit, subjects with any psychiatric disorder had a mean weight loss of 1.2% of baseline weight compared with 7.8% weight loss in subjects with no diagnosis. Discussion: These results suggest that the presence of psychiatric disorders can interfere with weight loss. Therefore, recognition and treatment of psychiatric disorders may be important in attempts at weight reduction, and this will be especially important in populations such as cancer survivors, who seem to have higher rates of depression and other disorders than the general population.     

Suicide among Manitoba's aboriginal people, 1988 to 1994

OBJECTIVE: To compare and contrast the characteristics of suicides among aboriginal and nonaboriginal people in Manitoba. DESIGN: Retrospective review of all suicides, based on a confidential analysis of records held by the Office of the Chief Medical Examiner. SETTING: Manitoba between 1988 and 1994. OUTCOME MEASURES: Standardized suicide rates, age- and sex-specific suicide rates, blood alcohol level at time of death, psychiatric help-seeking behaviour before suicide and residence on a reserve. RESULTS: Age-standardized suicide rates were 31.8 and 13.6 per 100,000 population per year among aboriginal and nonaboriginal people, respectively. The mean age of aboriginal people who committed suicide was 27.0 (standard deviation [SD] 10.8) years, compared with a mean age of 44.6 (SD 18.8) years for nonaboriginal people who committed suicide (p < 0.001). Blood alcohol levels at the time of death were a mean of 28 (SD 23) mmol/L among aboriginal people and 12 (SD 20) mmol/L among nonaboriginal people (p < 0.0001). Before their death, 21.9% of nonaboriginal suicide victims had sought psychiatric care whereas among aboriginal suicide victims 6.6% had sought care (p < 0.0001). Although the suicide rate was higher among aboriginal people living on reserve than among those living off reserve (52.9 v. 31.3 per 100,000 per year), both of these rates were substantially higher than the overall rates among nonaboriginal people. There were no significant differences in mean age, sex, blood alcohol level and previous psychiatric care among aboriginal people who committed suicide living on and off reserve. CONCLUSIONS: There was a high rate of suicide among Manitoba''s aboriginal people between 1988 and 1994; this rate was comparable to earlier estimates of national suicide rates among aboriginal people. The reserve environment does not, by itself, account for the high suicide rate among Manitoba''s aboriginal people. Further study of help-seeking behaviour and the association between alcohol abuse and suicide, particularly among aboriginal peoples, is indicated.     

Dicrimination of systolic blood pressure

The ability of humans to discriminate systolic blood pressure (BP) was investigated in two experiments. In Experiment 1, 14 normal subjects were asked to make estimates of their systolic BP while performing both BP-elevating and BP-lowering tasks. They were given intermittent feedback throughout all 10 45-min sessions. Results indicated significant correlations and small absolute differences between estimated and measured BP for all subjects in almost all sessions. Experiment 2, undertaken 6 months after Experiment 1, assessed whether estimation accuracy by subjects who had available both external and interoceptive cues surpassed that of subjects which access to external cues only. Three subjects from the original group who showed consistently high motivation, and who improved in accuracy across the 10 sessions in the previous experiment, made estimates of BP while performing novel tasks with no feedback. Correlations between estimated and measured BP remained high for 2 of the 3. These results were compared with the accuracy of control subjects (3 for each experimental subject) who were asked to estimate experimental subjects' BP using only the cognitive information available to the experimental subjects. Control subjects also had high correlations between their estimates and the experimental subjects' measured BP but at lower levels than two experimental subjects. These findings are discussed in relation to subjects' possible use of interoceptive information.     

Characteristics of pregnant women who engage in binge alcohol consumption

OBJECTIVE: To characterize pregnant women who engage in binge drinking and to identify other risk behaviour that these women engage in. DESIGN: Observational study based on retrospective review of records. SETTING: A telephone and outpatient counselling service in Toronto that advises pregnant women about exposure to drugs, chemicals, radiation and infections during pregnancy and lactation. PARTICIPANTS: All pregnant women who sought counselling concerning fetal risk of exposure to binge drinking from 1985 to 1994 as well as those counselled by telephone from 1993 to 1994, and an equal number of control women who sought counselling. OUTCOME MEASURES: Information about binges, demographic factors, history of elective and spontaneous abortion, and use of psychotropic drugs and cigarettes as well as marijuana, cocaine and other illicit drugs. RESULTS: Of the 3800 women seen in the clinic, 119 (3.1%) reported binge drinking during pregnancy; of the 19,991 women counselled by telephone, 153 (0.8%) reported binge drinking during pregnancy. The mean number of drinks per binge was 7.2 (standard deviation 2.5). None of the women was an alcoholic; 83.1% had binged fewer than 10 times during their pregnancy. A large majority (84.0%) of the women had a binge early in the first trimester (before 6 weeks'' gestation). In comparison with control women, the women who had engaged in binge drinking were significantly younger (mean 30.0 v. 27.9 years, p < 0.0001) and more likely to be single (12.2% v. 54.6%, p < 0.0001), to be white (69.2% v. 92.9%, p < 0.004), to smoke (19.3% v. 57.1%, p < 0.0001) and to use cocaine (1.1% v. 11.0%, p < 0.0001), marijuana (3.0% v. 19.3%, p < 0.0001) and other illicit drugs (0.7% v. 9.2%, p < 0.0001). CONCLUSIONS: Pregnant women who report binge alcohol consumption often report use of cigarettes, cocaine, marijuana and other illicit drugs as well, all of which represent a significant risk to the fetus. Rigorous efforts should be made to prevent the socially accepted binge consumption of alcohol among young, sexually active women.     

Increased risk of recurrence of pregnancies complicated by fetal neural tube defects in mothers receiving poor diets,and possible benefit of dietary counselling.

One hundred and seventy-four women who had previously had a child with a neural-tube defect were assessed retrospectively on the quality of their diets during the first trimester of that pregnancy, between pregnancies, and during the first trimester of other pregnancies. They were then studied prospectively during the first trimester of 186 following pregnancies and the outcome of these was recorded. One hundred and three women (with 109 pregnancies) were given dietary counselling before the pregnancy, the remaining 71 (with 77 pregnancies) not being counselled. Seventy-eight (72%) of the counselled women improved their diet compared with only nine (12%) of the uncounselled women. The difference was significant (p < 0.001). There were three recurrences of neural-tube defects in the counselled women (3%) and five recurrences in the uncounselled (7%). Although this difference was not significant, the relative risk in the counselled group was reduced to less than half of that in the uncounselled group. All eight recurrences occurred in the 45 pregnancies in women taking poor diets (18%), whereas there were no recurrences in the 141 other pregnancies. This difference is significant (p < 0.001). It is concluded that women receiving adequate diets have a lower incidence and recurrence of fetal neural-tube defects than women receiving poor diets and that dietary counselling may be effective in reducing the incidence of fetal neural-tube defects.     

Self-induced vomiting and bulimia nervosa: an undetected problem.

Six hundred and twenty women who were currently practising self-induced vomiting to control their weight were identified with the help of a women''s magazine. Nineteen women (3.1%) fulfilled diagnostic criteria for anorexia nervosa. Of the remainder, 499 (83.0%) fulfilled diagnostic criteria for bulimia nervosa, a recently described eating disorder. Of these, 56.1% practised self-induced vomiting at least once daily; the mean duration of vomiting was 4.5 years. Most women were of normal body weight. On standardised measures, 68.1% of women showed pronounced psychiatric morbidity and 89% had profoundly disturbed attitudes to food and eating. 56.4% thought they definitely needed medical help, though only 30.1% had ever discussed any aspect of their eating difficulties with a doctor. This study highlights the secrecy that surrounds bulimia nervosa and suggests that it is an important undetected source of psychiatric morbidity.     

Attitudes to the psychiatric outpatient clinic.

Fifty patients were interviewed before their first ever appointment at a psychiatric outpatient clinic about their attitude to the forthcoming visit. Many did not know that it was a psychiatrist they were to see at the hospital. Widespread misconceptions about the nature of a psychiatric consultation were uncovered. Many felt the referral carried an implicit threat of social stigma. Patient''s misconceptions were relieved, and only 13% subsequently failed to attend the clinic compared with 30% of a control group.     

Psychiatric illness in inpatients with neurological disorders: patients' views on discussion of emotional problems with neurologists.

The prevalence of psychiatric morbidity in inpatients with neurological disorders and the extent to which it is detected by neurologists were measured by using a two stage model of psychiatric assessment and from information recorded in the patients'' medical notes. The prevalence of psychiatric morbidity was estimated as 39%, of which 72% was unrecognised by the neurologists. Only a minority of patients with an uncertain physical diagnosis had a psychiatric illness, showing the error in assuming that a patient''s physical symptoms arise from a psychological disturbance if an organic aetiology cannot be determined. When the patients were interviewed on their discharge from hospital they were divided on whether they had wished to discuss their mood with neurologists while they were in hospital. The reasons that they gave suggested that interactions between patients and doctors and the lack of ward facilities for private consultations with doctors are important determinants of hidden psychiatric morbidity in medical inpatients.     

Subtypes of Ataques de Nervios: The Influence of Coexisting Psychiatric Diagnosis

The current study assesses the relationship between presenting symptomatology of the self-labeled Hispanic popular diagnosis of ataques de nervios and the specific co-morbid psychiatric diagnoses. Hispanic subjects seeking treatment at an anxiety disorders clinic (n = 156) were assessed with a specially designed self-report instrument for both traditional ataque de nervios and panic symptoms, and with structured or semi-structured psychiatric interviews for Axis-I disorders. This report focuses on 102 subjects with ataque de nervios who also met criteria for panic disorder, other anxiety disorders, or an affective disorder. Distinct ataque symptom patterns correlated with co-existing panic disorder, affective disorders, or other anxiety disorders. Individuals with both ataque and panic disorder reported the most asphyxia, fear of dying, and increased fear during their ataques. People with ataques who also met criteria for affective disorder reported the most anger, screaming, becoming aggressive, and breaking things during ataques. Ataque positive subjects with other anxiety disorders were less salient for both panic-like and emotional-anger symptoms. The findings suggest that (a) ataque de nervios is a popular label referring to several distinct patterns of loss of emotional control, (b) the type of loss of emotional control is influenced by the associated psychiatric disorder, and (c) ataque symptom patterns may be a useful clinical marker for detecting psychiatric disorders. Further study is needed to examine the relationship between ataque de nervios and psychiatric disorders, as well as the relationship to cultural, demographic, environmental, and personality factors.     

The Isis Centre: a counselling service within the National Health Service.

A new centre has been established to provide readily accessible counselling, consultation, and mental health information. People may refer themselves or are recommended to attend by general practitioners or other agencies. The counsellors have varied backgrounds in paramedical or counselling services, and they are supported by psychiatrists. Of a sample of 100 clients, four were referred to one of the team''s psychiatrists and 33 visited the centre only once. The centre''s staff aim to adopt a flexible approach to the client and his problems, and formal psychiatric categories have not been found useful. Provision is made for people who want to solve their problems by discussion rather than medication and those for whom the existing psychiatric services may have little time to spare. Consequently, the approach adopted by the Isis Centre, whereby many people benefit from psychotherapy yet the psychiatrist deals directly with only a few selected cases, contributes towards meeting the great need for psychiatric services and using the psychiatrist''s skills more effectively.     

Psychiatry in General Practice

Psychiatrists should include the family doctor in their plans for future psychiatric services. The general practitioner now treats most of the patients who seek help for psychiatric disorder and he could not give up his psychiatric practice even if he wanted to. Furthermore, there are not now nor will there ever be enough psychiatrists to take over all patients with mental ills. Most emotionally disturbed patients can be better handled by their family physicians than by a specialist.To provide the best care for emotionally disturbed people the communication between family doctors and psychiatrists must be improved. The specialist must acknowledge the importance of the general practitioner''s role in psychiatric diagnosis and treatment and give him more help. Medical schools must provide better undergraduate and postgraduate psychiatric training for the students who will become family doctors. Health plans and other prepayment agencies should properly compensate the general practitioner for giving psychiatric treatment. The specialist in psychiatry should consult more readily with the general practitioner and help him carry out some of the therapy. General hospitals should permit family doctors to admit mental patients to psychiatric wards in a general hospital and to carry out psychiatric treatment with the help of the specialist in psychiatry.     

Outbreaks of salmonella infection in hospitals in England and Wales 1978-87.

A total of 248 outbreaks of salmonella infection in hospital affecting over 3000 patients and 110 associated deaths were ascertained in England and Wales in 1978-87, compared with 522 outbreaks of salmonella in 1968-77. The largest reduction was found in outbreaks from children''s units and maternity units. Fifty seven (24%) outbreaks were considered to be due to foodborne salmonellosis, and 70 (30%) were reported as person to person spread of the infection. The psychiatric hospital was the type of hospital in which foodborne outbreaks most often occurred, but the risk of being affected in an outbreak not due to food seemed to be highest in maternity units. Better control of infection and better surveillance should lead to earlier investigation and control of outbreaks.     

‘I need help’: caregivers' experiences of caring for their relatives with mental illness in Jamaica

The findings reported here form part of a larger research project that examined non-compliance with medication among the mentally ill patients attending public clinics in a specific parish in Jamaica. The aim of the research was to explore the perceptions of caregivers about caring for the mentally ill at two outpatient psychiatric clinics. Caregivers involved in looking after their relatives with mental illness played a vital role in mental health promotion. This study sought to examine the caregivers'' perception of mental illness, including how they thought the illness was best controlled, the reasons why their relatives found it difficult to take their medication as instructed, and the coping skills that they employed when caring for their relatives. There were two focus groups, consisting of four individuals each, at two psychiatric clinics.The results revealed the following about the majority of the caregivers. First, it was recognised that caregivers have a good knowledge (and awareness) of medication usage inferred by either the absence or the presence of their relatives'' symptoms. Secondly, they sometimes felt sad and hopeless as a result of being the victims of violent attacks by those for whom they provided care. Thirdly, they highlighted issues of cost, accessibility and availability of medications as being problematic. Fourthly, in some cases they received little or no assistance from other family members.     

Prevalence of Mental Illness among Homeless People in Hong Kong

MetholodogyThis study examined the prevalence and correlates of mental illness in homeless people in Hong Kong and explored the barriers preventing their access to health care. Ninety-seven Cantonese-speaking Chinese who were homeless during the study period were selected at random from the records of the three organisations serving the homeless population. The response rate was 69%. Seventeen subjects could not give valid consent due to their poor mental state, so their responses were excluded from the data analysis. A psychiatrist administered the Structured Clinical Interview for DSM-IV Axis-I disorders (SCID-I) and the Mini -Mental State Examination. Consensus diagnoses for subjects who could not complete the SCID-I were established by three independent psychiatrists.FindingsThe point prevalence of mental illness was 56%. Seventy-one percent of the subjects had a lifetime history of mental illness, 30% had a mood disorder, 25% had an alcohol use disorder, 25% had a substance use disorder, 10% had a psychotic disorder, 10% had an anxiety disorder and 6% had dementia. Forty-one percent of the subjects with mental illness had undergone a previous psychiatric assessment. Only 13% of the subjects with mental illness were receiving psychiatric care at the time of interview. The prevalence of psychotic disorders, dementia and the rate of under treatment are hugely underestimated, as a significant proportion (18%) of the subjects initially selected were too ill to give consent to join the study.ConclusionThe low treatment rate and the presence of this severely ill and unreached group of homeless people reflect the fact that the current mode of service delivery is failing to support the most severely ill homeless individuals.