District programme to reduce smoking: effect of clinic supported brief intervention by general practitioners.

By encouraging and supporting general practitioners to undertake brief intervention on a routine basis smokers'' clinics could reach many more smokers than are willing to attend for intensive treatment. In a study with 101 general practitioners from 27 practices 4445 cigarette smokers received brief intervention with the support of a smokers'' clinic, brief intervention without such support, or the general practitioners'' usual care. At one year follow up the numbers of smokers who reported that they were no longer smoking cigarettes were 51 (13%), 63 (9%), and 263 (8%), respectively (p less than 0.005). After an adjustment was made for those cases not validated by urine cotinine concentrations the respective success rates were 8%, 5%, and 5%. Use of nicotine chewing gum was associated with higher self reported success rates. General practitioners providing supported brief intervention encouraged not only more smokers to use the gum but also more effective use; gum users in this group reported a success rate of 27% at one year. Compliance by the general practitioners in recording smoking state averaged 45%, and significantly higher success rates were reported by patients whose smoking state had been recorded. Brief intervention by general practitioners with the support of a smokers'' clinic thus significantly enhanced success rates based on self reports. Better results might be obtained if general practitioners'' compliance with the procedure could be improved and if they encouraged more of their patients to try nicotine gum. Collaboration of this kind between a smokers'' clinic and local general practitioners could deliver effective help to many more smokers than are likely to be affected if the two continue to work separately.     

Results of Psychotherapy

A controlled double blind study was made of 299 non-psychotic female psychiatric clinic patients divided into six groups, with members of each group dealt with in a different manner from those in other groups. Those in one group had one or two hour-long psychotherapy sessions a week. Four groups were limited to brief visits but were given one of three kinds of drugs or a placebo. One group was merely put on a waiting list and received no therapy. As determined by a variety of independent measures, there was a fairly uniform average improvement of all groups except the one that received no treatment. Follow-up 10 to 18 months after termination of treatment revealed that the average patient had maintained her improvement and that those who had received no treatment showed considerable improvement after they were removed from the waiting list.The findings suggested that the widespread preference for the traditional outpatient psychotherapy is based as much on the physician''s bias as on proven greater effectiveness over briefer treatment methods. There was some confirmation that many things other than the development of understanding enter into much of the so-called psychoanalytically oriented psychotherapy and may have profound effect on the outcome.     

NEWER THERAPY FOR LEUKEMIA,POLYCYTHEMIA, AND LYMPHOMA

X-radiation remains the treatment of choice in most cases of leukemia and lymphoma, but new agents are playing an increasing role in therapy. Radioactive phosphorus does not produce radiation sickness and results with it are comparable to those of x-ray therapy in chronic leukemia. Urethane and nitrogen mustard may produce remissions in patients with chronic leukemia who have become resistant to radiation. Triethylene melamine may be administered orally with nitrogen mustard-like effects and is undergoing further trial. Aminopterin, ACTH and cortisone often cause short remissions in acute leukemia. Urethane is the best treatment available for multiple myeloma. Polycythemia vera is well controlled by radioactive phosphorus combined with venesection. Nitrogen mustard is often effective and triethylene melamine shows promise in Hodgkin''s disease. Antianemic substances such as iron and liver extract are of no value in the treatment of anemia caused by leukemia, lymphoma and myeloma.     

Effect of Psychiatric Intervention in Attempted Suicide: A Controlled Study

All patients presenting at the casualty department of King''s College Hospital during the first six months of 1968 with deliberate self-poisoning or self-injury were followed up. Of 211 patients 204 (97%) were traced after a mean interval of 18 months (range one to two years). Despite official hospital policy, 22% had not been seen by a psychiatrist before discharge; these 44 untreated patients were compared with the remaining 160 who had received either brief (one or two interviews) or more prolonged psychiatric and social help.Subsequent suicidal attempts occurred significantly more often among untreated than among treated patients, prolonged treatment being associated with the best prognosis. The same trend was observed in respect of actual suicide, though the numbers were small and differences did not reach statistical significance. These findings held good when the untreated and treated groups were controlled for other variables which were found to be correlated with outcome. These results indicate that psychiatric intervention is associated with a significant reduction in subsequent suicidal behaviour.     

Privileged Communications—The Effect of California's New Evidence Code As It Concerns Physicians and Psychotherapists

A physician has an ethical duty to hold in confidence communications made to him by his patient. A legal recognition of this ethical duty is found in the concept of privilege, which is the subject of this article. January 1967 will bring to California physicians a new protection for patients'' communications. The physician-patient privilege has been redefined to include confidential communications made during diagnostic evaluation, those made to non-licensed physicians, interns and medical aides, and those overheard by eavesdroppers. There has been added a psychotherapist-patient privilege designed to facilitate communications required in psychotherapy as well as in behavioral research.This paper first presents a brief historical background and discusses the protections and limitations afforded by the new California Evidence Code. There follows a section on the psychotherapist-patient privilege with the recommendation that in the context of psychotherapy, patients of physicians who are not psychiatrists should be afforded the additional benefits of the psychotherapist-patient privilege. Lastly, advice is given concerning the physician''s conduct in relation to his duty to claim privilege under the new code.     

PSYCHOTHERAPY OF FUNCTIONAL DERMATOSES,Its Value and Limitations as Applied to Neurodermatitis

Etiologically, neurodermatitis is interpreted as an often manifestly hereditary diathesis which is frequently complicated and exacerbated by disturbances of the patient''s emotional and psychic structure. The following traits are commonly exhibited, singly or in combination: a tendency toward excitability and an exaggerated capacity for response to stimuli, polyvalent dermal hypersensitivity, a propensity to vascular disturbances, a personality somewhat obsessional in structure and evidence of deep-seated emotional conflict.Shallow psychotherapy, an indispensable adjunct to the treatment of neurodermatitis, can be successfully applied by any dermatologic physician adequately endowed with patience, sympathy and tact. This method does not achieve a cure, but, properly applied, it can immeasurably improve the patient''s lot.     

The clinical psychologist; his role in private medical practice

The independent diagnosis and treatment of mental and nervous disorders according to California law constitutes practicing medicine. By this yardstick, an increasing number of clinical psychologists are entering the private practice of medicine. The medical profession has not provided through its leadership the opportunity for clinical psychologists to utilize their skills in a legitimate and supervised way in the treatment of private patients, nor has the medical profession taken sufficient interest in modern methods of treating patients with psychogenic disorders. If the psychiatric team is a feasible and practical approach to spreading the base of psychiatric treatment in hospitals and clinics, it should be applicable to private practice settings too. In the team setting, the psychologist can render great assistance to the physician in the diagnosis and treatment of patients with psychogenic disorders without compromising the principle that the primary responsibility for the patient is the physician's. By virtue of his training and experience, it is the psychiatrist who is best qualified to supervise the work of the psychologist; and until such time as the medical profession is better acquainted with psychotherapeutic techniques, the employment of psychologist assistants should be (according to good medical practice) left to the psychiatrist. The need for some regulation of the use of the title "psychologist" is increasing in order to protect the public from quacks who pose as psychologists. However, any law which is directed toward elimination of the quack should specifically define psychotherapy and contain provisions for its use under adequate medical supervision. The medical profession is obligated to take its traditional role in providing the best possible treatment for patients who are in need of it, and psychotherapy is an inherent part of treatment.     

A network meta‐analysis of the effects of psychotherapies,pharmacotherapies and their combination in the treatment of adult depression

No network meta‐analysis has examined the relative effects of psychotherapies, pharmacotherapies and their combination in the treatment of adult depression, while this is a very important clinical issue. We conducted systematic searches in bibliographical databases to identify randomized trials in which a psychotherapy and a pharmacotherapy for the acute or long‐term treatment of depression were compared with each other, or in which the combination of a psychotherapy and a pharmacotherapy was compared with either one alone. The main outcome was treatment response (50% improvement between baseline and endpoint). Remission and acceptability (defined as study drop‐out for any reason) were also examined. Possible moderators that were assessed included chronic and treatment‐resistant depression and baseline severity of depression. Data were pooled as relative risk (RR) using a random‐effects model. A total of 101 studies with 11,910 patients were included. Depression in most studies was moderate to severe. In the network meta‐analysis, combined treatment was more effective than psychotherapy alone (RR=1.27; 95% CI: 1.14‐1.39) and pharmacotherapy alone (RR=1.25; 95% CI: 1.14‐1.37) in achieving response at the end of treatment. No significant difference was found between psychotherapy alone and pharmacotherapy alone (RR=0.99; 95% CI: 0.92‐1.08). Similar results were found for remission. Combined treatment (RR=1.23; 95% CI: 1.05‐1.45) and psychotherapy alone (RR=1.17; 95% CI: 1.02‐1.32) were more acceptable than pharmacotherapy. Results were similar for chronic and treatment‐resistant depression. The combination of psychotherapy and pharmacotherapy seems to be the best choice for patients with moderate depression. More research is needed on long‐term effects of treatments (including cost‐effectiveness), on the impact of specific pharmacological and non‐pharmacological approaches, and on the effects in specific populations of patients.     

Les psychotherapies breves psychodynamiques et relationnelles et leur emploi actuel dans le traitement des dysfonctions sexuelles

Brief psychodynamic or interpersonal therapeutic techniques, which were developed mainly in the UK and USA, are either derived from psychoanalysis or are closely related to it. The use of standardized methods during their development allowed them to be used in research protocols in the same way as biological treatments. Consequently, their general efficacity was established during the 1980s based upon reliable data. These techniques’ foundation upon common underlying mechanisms of action allowed the use of several psychotherapeutic techniques either within a given patient or by an individual therapist. Subsequently, generalized psychotherapeutic models based on the various methods were elaborated, resulting in the widespread applicability of these techniques. In the treatment of sexual disorders brief psychotherapeutic techniques now address more complex intrapsychic factors or interpersonal problems involved in sexual dysfunction than did the sex therapy models of Masters and Johnson and their early followers. Two types of situations can be distinguished where the indications are either symptomatic or non-symptomatic, although such a dichotomy may be too strict. The latter category is more of an individual situation where attention is not concentrated on the sexual symptoms but deals more with the patient’s general problems. The former category deals mainly with treating a couple’s secondary sexual disorder problem(s) where attention is focussed on the symptoms and is often associated with prescribing behavioural tasks. Debate over the use of intracavernosal injections in association with psychotherapy continues. In conclusion, the efficacy of dynamic and interpersonal psychotherapeutic techniques has now been established; although their use in the field of sexual disorders must be complementary, not concurrent, to biological treatments. This is an area of continued scientific research     

THE PSYCHOTHERAPEUTIC APPROACH TO EMOTIONAL PROBLEMS

Physicians are confronted with more and more psychological problems in their daily practice. Not only must a physician be able to recognize the problems, he must also be prepared to treat a certain number of them. Some of the patients will improve just because of a good relationship with the physician. Others will require more definitive, yet comparatively simple, psychotherapy. On the other hand, some patients with clear-cut emotional problems are best treated by the physician''s traditional medical approach rather than by some type of “formal” psychotherapy. In some circumstances psychotherapeutic efforts may be damaging.     

THE EFFECT OF VARIOUS FIXATION SCHEDULES ON THE SCANNING ELECTRON MICROSCOPIC IMAGE OF TROPAEOLUM MAJUS

Fresh, unfixed shoot tips of Tropaeolum provided excellent quality scanning electron micrographs if observations were brief and magnifications were relatively low. For extended observations or for high-magnification observations, fixation by OsO₄ vapor or Zirkle-Erliki's fluid provided the best scanning electron micrographs. Brief exposures to microscope vacuum do not appear to produce any apparent morphological changes in living shoot tips of Tropaeolum except in regions adjacent to a cut surface.     

Persistence of Psychological Distress in Surgical Patients with Interest in Psychotherapy: Results of a 6-Month Follow-Up

Objectives

This prospective observational study investigated whether self-reported psychological distress and alcohol use problems of surgical patients change between preoperative baseline assessment and postoperative 6-month follow-up examination. Patients with preoperative interest in psychotherapy were compared with patients without interest in psychotherapy.

Methods

A total of 1,157 consecutive patients from various surgical fields completed a set of psychiatric questionnaires preoperatively and at 6 months postoperatively, including Patient Health Questionnaire-4 (PHQ-4), Brief Symptom Inventory (BSI), Center for Epidemiologic Studies Depression Scale (CES-D), World Health Organization 5-item Well-Being Index (WHO-5), and Alcohol Use Disorder Identification Test (AUDIT). Additionally, patients were asked for their interest in psychotherapy. Repeated measure ANCOVA was used for primary data analysis.

Results

16.7% of the patients were interested in psychotherapy. Compared to uninterested patients, they showed consistently higher distress at both baseline and month 6 regarding all of the assessed psychological measures (p’s between <0.001 and 0.003). At 6-month follow-up, neither substantial changes over time nor large time x group interactions were found. Results of ANCOVA’s controlling for demographic variables were confirmed by analyses of frequencies of clinically significant distress.

Conclusion

In surgical patients with interest in psychotherapy, there is a remarkable persistence of elevated self-reported general psychological distress, depression, anxiety, and alcohol use disorder symptoms over 6 months. This suggests high and chronic psychiatric comorbidity and a clear need for psychotherapeutic and psychiatric treatment rather than transient worries posed by facing surgery.     

Attitudes of Ontario psychiatrists towards health insurance.

In 1979 the opinions of Ontario psychiatrists were sought regarding the influence of the Ontario Health Insurance Plan (OHIP) on the practice of their specialty. Full replies to a 44-item questionnaire were received from more than half the certified psychiatrists in Ontario, half of whom had been in practice before the introduction of OHIP. Both satisfaction and uneasiness were expressed about most aspects of health insurance. Many of the 416 psychiatrists stated that OHIP had improved access to psychiatric care, providing a more socially diverse practice, especially with respect to psychotherapy. Only one quarter believed that OHIP constituted a major intrusion on the doctor-patient relationship, and the majority reported that OHIP had been beneficial to themselves as psychiatrists (70%) and to their patients (86%). Almost half reported having raised their concern about the confidentiality of OHIP records with their patients; the patients less often brought up the issue. Although most psychiatrists in practice before the introduction of OHIP reported no change in their conduct of psychotherapy, a minority reported a decrease in the duration of treatment and an increase in the frequency of missed appointments. Also noted was an increase in the number of referrals for consultation, which led at times to overutilization of these specialists'' services.     

NONVERBAL TREATMENT OF NEUROSIS—Techniques for General Practice

“Psychosomatic medicine” does not demand that the general practitioner function as a psychiatrist; rather, it is a psychiatric orientation that can increase the effectiveness of purely medical treatment for such conditions as neuroses. The general practitioner to whom the patient turns may achieve permanent results with nonverbal techniques where formal psychotherapy would be impracticable or unacceptable.The first aim is to relieve pressure so that the patient can regain his mental balance and thereby his self-confidence. Arts, hobbies, sports, and the like can be prescribed rather specifically according to the patient''s personality and needs. Nutrition can be improved simply at first by prescribing needed additions to diet rather than imposing restrictions. Vitamin deficiency may by itself be the cause of neurosis or more serious mental disease, whereas psychic stress by itself may create a need for additional vitamin intake. Hormone therapy may be extremely helpful but must be based on clear indication and limited to specific purposes.Since lack of sleep and rest quickly impairs mental function, it is important for neurotic persons to learn relaxation as a necessity for sleep. Sedatives may be used in a crisis but should be abandoned as soon as possible.With all drugs there are problems of excess and habituation. The least, the mildest, the shortest dosage is the ideal.The initial steps of psychotherapy are available to any physician: Establishing rapport, noting how complaints are stated, encouraging ventilation, winning confidence rather than immediate results.     

Tricuspid Valve Replacement in Rheumatic Heart Disease

The diagnosis of tricuspid valve disease is often difficult; the best treatment is not yet established. Twenty patients had tricuspid valve replacements at St. Thomas''s Hospital as part of multiple valve replacement procedures. The hospital mortality was 25%, most deaths being due to a low cardiac output causing hepatorenal failure. Preoperative cardiac cachexia had a fatal outcome in all cases. Except in two instances, surviving patients returned to a satisfactory level of activity.     

Focus: Microbiome: Integrative Therapies in Anxiety Treatment with Special Emphasis on the Gut Microbiome

Over the past decade, research has shown that diet and gut health affects symptoms expressed in stress related disorders, depression, and anxiety through changes in the gut microbiota. Psycho-behavioral function and somatic health interaction have often been ignored in health care with resulting deficits in treatment quality and outcomes. While mental health care requires the professional training in counseling, psychotherapy and psychiatry, complimentary therapeutic strategies, such as attention to a nutritional and diverse diet and supplementation of probiotic foods, may be integrated alongside psychotherapy treatment models. Development of these alternative strategies is predicated on experimental evidence and diligent research on the biology of stress, fear, anxiety-related behaviors, and the gut-brain connection. This article provides a brief overview on biological markers of anxiety and the expanding nutritional literature relating to brain health and mental disorders. A case study demonstrates an example of a biopsychosocial approach integrating cognitive psychotherapy, dietary changes, and mindfulness activities, in treating symptoms of anxiety. This case study shows a possible treatment protocol to explore the efficacy of targeting the gut-brain-axis that may be used as an impetus for future controlled studies.     

Une approache pratique des résistances psychologiques aux traitements par injections intracaverneuses (I.I.C.)

Intra-cavernous injection of vasoactive substances has dramatically modified the medical approach of erectile dysfunction. There are psychological and ethical difficulties to this therapeutic procedure, and it is likely that they do contribute to the high drop out rate encountered with this method. According to our clinical experience, we suggest several attitudes in order to facilitate patient's and partner's acceptance:

? There is no opposition between psychotherapy and intra-cavernous injection, they may be regarded as complementary.

? It is advisable to find means to reduce the fear induced by self injection, by reassuring the patient, and making the act easier by choosing the most simple injection material. The pharmacological action must be explained, as well as the side effects.

? Pharmacologically induced erection is often described as artificial, although intra-cavernous injection of vasoactive substances is a symptomatic treatment just as many other symptomatic treatments. It compensates a functional insufficiency, restoring a physiological state very close to normal as far as erection is concerned, but has no effect on sexual excitation, glans intumescence and the development of the ejaculatory climax reflex. The sexuel relation's erotization lays only within the couple, and remains entirely apart from any iatrogenic effect.

? Should the treatment remain secret? Inta-cavernous injection must not systematically be performed withtout the partner knowing about it, although the act should remain discrete and intimate.

One should not encounter psychic or ethical difficulties in erectile dysfunction treatment with intra-cavernous injection of vasoactive substances, provided that it has been properly prescribed, well explained, and that it is part of a psychotherapy. It is doubtless that many refusals or therapy withdrawals are caused by poor or lack of technical initiation, on one hand, and by not taking into account the psychic and ethical aspects of the method, on the other hand.     

Fine Structure and Biomineralization of the Mucilage in Envelopes of Trachelomonas lefevrei (Euglenophyceae)1

Envelope development in Trachelomonas lefevrei (Deflandre) begins with the production of short, coarse mucilaginous strands, morphologically similar to the mucilage produced by non-enveloped euglenoids. These initial mucilaginous secretions subsequently become impregnated with manganese (Mn) and/or iron (Fe). Continued mucilage secretion and mineralization results in a mature envelope that is characteristic for the species. When these mature envelopes are treated with oxalic acid to remove the Mn and Fe, the envelopes collapse and are composed only of short, coarse mucilaginous strands similar to those present during early stages of development, prior to their mineralization. Brief treatment with 10 mM EDTA renders dark envelopes colorless, and our EM-EDS analyses show that this corresponds to a loss of Mn from the envelope; however, if Fe is present in the envelope, it is unaffected by the brief treatment. The mucilage present during early stages of envelope development and that remaining after complete demineralization is also morphologically similar to the mucilage in the plug at the anterior end of the envelope.