Psychosexual dysfunction in women with gynaecological cancer following radical pelvic surgery

OBJECTIVE

To assess the prevalence and severity of psychosexual dysfunction in women treated for cancer of the cervix and vulva by radical vulvectomy, Wertheim's hysterectomy and pelvic exenteration; and to identify the risk factors for sexual morbidity and ways in which it might be reduced.

DESIGN

Retrospective study of patients by questionnaire and semistructured interview, 6 months to 5 years following surgery.

SETTING

Gynaecology-Oncology Unit of a general hospital.

PATIENTS

105 English speaking women with gynaecological cancer.

RESULTS

90% of the women in relationships had been sexually active prior to surgery. Of this group, 24% had no sexual difficulties post-operatively; 66% of the latter still had problems more than 6 months later, and 15% of the latter never resumed intercourse (excluding those with a colpectomy). 82% of those aged less than 50 years who had had radiotherapy suffered sexual dysfunction. Lack of desire was the commonest problem, and half the women felt that their sexual relationship had deteriorated, yet only 16% felt that their marriage had worsened. Younger women were more likely to attribute personal and marital distress to their sexual problems. More information on sexual matters would have been liked by 28% of the women.

CONCLUSIONS

Sexual dysfunction is common following radical pelvic surgery and tends to remain a chronic problem. As well as organic causes there is a strong psychogenic element brought about by loss of fertility, disfigurement, depression and anxiety about one's desirability as a sexual partner. The presence of a stable relationship before the diagnosis of cancer helps women cope better, and young single women are a very vulnerable group. Patients want more information on sexual matters and the provision of sexual counselling may improve outcome in the future.

Physical symptom severity, psychological and social dysfunction in a series of outpatients with irritable bowel syndrome

Details of physical symptoms, psychological and social dysfunction of 42 outpatients diagnosed as having irritable bowel syndrome (IBS) were collected by interview and questionnaire. Social stresses and problems were also elicited as well as the impact of symptoms on their subjects' daily lives. High proportions of subjects were handicapped in their social, sexual and working lives by IBS symptoms and social stresses and problems were common. Forty-eight per cent were classified as having a 'minor psychiatric illness' using the Clinical Psychiatric Interview. Women were more severely affected by physical symptoms (with the exception of diarrhoea) and were more likely to be in pain longer and for more days in the month. They were also more likely than men to be diagnosed as having a psychiatric illness.

The construction, development and testing of a self-report questionnaire to identify social problems

The construction and testing of a short self-report questionnaire identifying social problems, difficulties and dissatisfactions is described. The questionnaire covers housing, occupation, finance, social and leisure activities, child/parent and martial relationships, relationships with relatives, friends, neighbours and workmates, and legal problems. The results of the administration of the questionnaire in a number of settings are provided and discussed, and a final version is included in the Appendix.

Sex differences in general practice attendance and help seeking for minor illness

Women's rates of utilization of almost all health care services are higher than men's. General practice surveys endorse these findings with women attending more frequently, particularly in the child bearing years. The present study sought to explore the variables associated with consultation and help seeking behaviour for minor illnesses. Samples of male and female low and high attenders aged between 20 and 45 were drawn from one general practice to investigate which factors were important in explaining sex differences in consultation. Analysis of the results suggests that attendance and help seeking in men and women was closely linked to physical illness, the presence of physical symptoms was predictive of more frequent consultation in both men and women. The presence of psychosocial problems or distress, however, predicted consultation behaviour in women but not in men. The women had more confidants and contacted more social agencies than the men, also suggesting that they found it easier to divulge personal information to others than the men. There was no evidence from this study that such enabling factors as physical accessibility and time available were related to differential attendance rates.

The care of patients undergoing surgery for gynaecological cancer: the need for information, emotional support and counselling

This study was undertaken by interviewing 105 patients who had undergone major gynaecological surgery for carcinoma of the cervix or vulva in the previous 5 years. A high proportion of the women was still found to be depressed and anxious when interviewed and the majority reported chronic sexual problems. The women were asked if they had received enough information regarding their illness and its treatment, and a high proportion would have liked to have had more information on the after-effects of the operation, including physical, sexual and emotional aspects. Many of the younger women would have liked their partner to have been included in the discussions and 25% of the 40 partners who responded to the questionnaire would have liked more information on the illness and its treatment. The women also indicated their needs for emotional support, discussion and counselling.

Psychosocial adjustment following major gynaecological surgery for carcinoma of the cervix and vulva

One-hundred and five women had undergone major gynaecological surgery for carcinoma of the cervix and vulva were interviewed retrospectively to elicit post-operative psychosocial and psychosexual problems. This interview took place between 6 months and 5 yr after surgery. Responses to the Hospital Anxiety and Depression Scale indicated that 20% of the women were 'probable' cases of anxiety and 21% were 'definite' cases. On the depression scale, 18% were 'doubtful' cases and 14% were 'definite' cases. Scores on the scales were not associated with age of the woman, the type of operation or the time period between being interviewed and the operation. Two-thirds of the women who were sexually active prior to the operation indicated ongoing sexual problems when interviewed and the presence of these problems was found to be significantly associated with the woman's level of anxiety.

A survey of 658 women who report symptoms of premenstrual syndrome

A treatment trial was briefly mentioned in two British publications and women suffering from premenstrual syndrome were invited to write to us. After initial screening, postal questionnaires were sent to all eligible women. Six-hundred and ninety-nine questionnaires were returned and of these 658 were included in the analyses. Although the results of the study need to be considered cautiously because of the unrepresentative nature of the sample, the survey was helpful in ascertaining the views of women who report PMS symptoms and what they had found helpful. The majority of respondents were aged in their 30s and were married with children. Over 60% were chronic sufferers, having had symptoms for 5 years or more. High proportions of the women experienced both psychological and somatic symptoms but it was the psychological symptoms which were perceived as the most distressing. Over 60% of the sample were ascertained as suffering from some degree of psychological distress and the same proportion had one or more social problems. Overall 84% had visited their GP for this problem and many had also visited gynaecologists, family planning clinicians and psychiatrists. Agencies offering alternative medicine were also frequently contacted and often found more helpful. Most women had tried more than one type of medication but no one treatment was found to be particularly helpful.

Behavioural psychotherapy in the treatment of irritable bowel syndrome

The irritable bowel syndrome is a highly prevalent condition whose underlying aetiology is not understood. While many patients respond to a combination of gastrointestinal antispasmodics, bulking agents and dietary manipulation, controlled clinical trials have suggested that the benefit is only marginal and is due mainly to the large placebo effect found in this condition, which has been calculated to range between 54 and 81%. Associations between the syndrome and psychological and social stresses suggest, however, that treatment involving a systematic approach to the management of symptoms may hold out real therapeutic possibilities. In the current study, 42 IBS patients were randomly allocated to either medical treatment or to behavioural psychotherapy with a nurse therapist. They were assessed initially and at 4 and 9 months. There was a general improvement over the 9 months on a number of physical and psychological symptoms measured. However, no differences were found between treatment groups except for changes in two avoidance scores. A significant correlation was found, however, between improvement in the bowel symptoms of IBS (stomach pain and diarrhoea) and improvement in the psychological symptoms measured by the Clinical Interview Schedule, suggesting a close interrelationship between the two.

A randomized controlled trial to evaluate the effectiveness and cost-effectiveness of psychodynamic counselling for general practice patients with chronic depression

BACKGROUND

Counsellors have been employed in general practice with little evidence of effectiveness. This study examined the effectiveness and cost-effectiveness of short-term counselling in general practice for patients with chronic depression either alone or combined with anxiety.

METHOD

A randomized controlled trial with an economic evaluation was carried out in Derbyshire. One hundred and forty-five patients were recruited at seven GP practices by screening using the Beck Depression Inventory. Both the experimental and control group received routine GP treatment but the experimental group were also referred to the practice counsellor. Depression, anxiety and other mental health symptoms, social and interpersonal functioning and social support were measured at baseline, 6 months and 12 months. Comprehensive costs were also estimated.

RESULTS

There was an overall significant improvement in the actual scores over time, but there were no significant differences between the two groups on any of the measures at either 6 or 12 months. However fewer experimental group patients were still 'cases' on the BDI than controls at 12 months. There were no significant differences in the mean total costs, aggregate costs of services, or any service-group costs except for primary care, between the experimental and control groups over time.

CONCLUSIONS

This trial demonstrates only very limited evidence of improved outcomes in those referred to counselling and increased primary care treatment costs in the short-term. Stricter referral criteria to exclude the more severely depressed in the group (BDI > or = 24) might have yielded more conclusive results.

Social work effectiveness in the management of depressed women: a clinical trial

A clinical trial was undertaken to assess the effectiveness of social work intervention with a group of depressed women attending their general practitioner for treatment. Social work treatment was ineffective for the group of women as a whole on changes in social scores, clinical ratings, or visits to the doctor. The results suggest, however, that social work help benefited those with ‘acute on chronic’ illness but had no effect on those with more acute conditions.

Marital problems and treatment outcome in depressed women. A clinical trial of social work intervention

In a clinical trial investigating the effectiveness of social work intervention with depressed women patients in general practice, 80 women were randomly allocated to an experimental group for referral to attached social workers or to a control group for routine treatment by their GPs. They were reassessed at 6 and 12 months. The results indicated that women who had major marital problems were more likely to be depressed at follow-up than those with good relationships. However, patients with marital difficulties in the experimental group made more improvement than the controls. Women initially assessed as suffering from 'acute on chronic' depression and having major marital difficulties were found to benefit most from social work intervention.

The mental and physical health of clients referred to social workers in a local authority department and a general practice attachment scheme

Although numerous reports have strongly argued that there is a need for a closer collaboration between the health and social services, studies investigating the health of clients in contact with the personal social services have been few and limited. This study collected information regarding the physical and mental health of clients referred to social workers in a local authority intake team and to a general practice attachment scheme by means of questionnaires completed by the client and at interview. The results indicated that the proportions of patients with physical or mental illness were very high. However, while social workers in the attachment scheme had many contacts with members of the primary care team regarding these clients, contacts between intake social workers and medical personnel were very limited.

The development of a self-report questionnaire to identify social problems--a pilot study

The construction of a short self-report questionnaire identifying social problems, difficulties and dissatisfactions is described. The questionnaire covers housing, occupation, finance, social and leisure activities, child—parent and marital relationships, relationships with relatives, friends, neighbours and workmates, and legal problems. Results of a preliminary testing in a general practice are provided and discussed, and plans for a more comprehensive assessment are outlined.

The effectiveness of attached social workers in the management of depressed female patients in general practice

There is a pressing need to evaluate the different forms of treatment for depressive illness encountered in general practice. This study consists of a controlled, randomized, clinical trial designed to investigate the effectiveness of social work intervention with depressed women. Eighty women aged between 18 and 45 were included and assessed initially by means of a psychiatric and social interview. Those ascertained to be suffering from 'acute' or 'acute on chronic' depression were randomly allocated to an experimental group who were referred to a social worker attached to a general practice or to a control group for routine treatment by their doctor. They were re-assessed 6 months later. Over 60% of both groups were clinically improved at follow-up, with no statistically significant differences between the two groups in clinical, social or medical outcome. Further analyses suggested, however, that those women initially assessed as suffering from 'acute on chronic' depression with major marital difficulties were found to benefit from social work treatment. These patients could be distinguished from the others by their high degree of motivation, by the initial severity of their problems and by the amount of practical help provided by the social workers.

Not a medical problem? An intensive study of the attitudes and illness behaviour of low attenders with psychosocial difficulties

An intensive study of female low attenders with significant psychosocial difficulties is described. Among the reasons for low reliance upon the help of their general practitioners are unsatisfactory past experiences of seeking help; a belief that health conditions with a pronounced psychosocial component are not amenable to medical intervention; and the availability of professional medical or social advisors in the immediate social network. The implications for the provision of primary care are discussed.

Why some adults with intellectual disability consult their general practitioner more than others

BACKGROUND

This research identifies factors affecting why some adults with intellectual disability (AWIDs) consult their general practitioner (GP) more than others. Little is known about these factors, despite AWIDs having higher health needs and reduced longevity. Current barriers to accessing health care need to be understood and overcome to achieve improved health outcomes.

METHODS

A secondary analysis of data obtained from a stratified randomised sample of AWIDs participating in a cluster randomised trial of hand held health records. The number of GP consultations was obtained retrospectively for the year preceding initial health interviews from GP records. AWIDs and their carers were given separate health interviews using identical/adapted questions where possible.

RESULTS

Two hundred and one AWIDs and or their carers from 40 practices participated (response rate 64.6%) with GP consultation data extracted for 187 AWIDs. Overall consulting levels were low, 3.2 per annum for women and 2.2 for men. Increased age, gender (women) and type of carer (paid) were all significantly associated with increased consultations. Carers reporting health problems, medications reported by AWIDs, medications recorded in GP records, and pain reported by AWIDs were also significant factors affecting consultations to GP practices after adjustment for age and type of carer.

CONCLUSIONS

Overall consultation rates were lower than expected, and affected by age, gender and type of carer. Targeted interventions are needed to improve attendance and promote health.

The extent of mental and physical ill-health of clients referred to social workers in a local authority department and a general attachment scheme

Information regarding the physical and mental health of clients referred to social workers in a local authority intake team and to a general practice attachment scheme was collected over a 3-month period. Although returns to the Department of Health and Social Security during this period indicated that a very low proportion of clients were physically or mentally ill, it is clear that these figures greatly underestimate the extent of illness present. While social workers operating outside hospital and general practice attachments have been shown to have little contact with medical staff, in this study high proportions of their clients were ill and their social problems were often associated with their illness.

Private provision of 'outreach' clinics to fundholding general practices in England

OBJECTIVES

To establish the contribution of the private sector in providing outpatient 'outreach' clinics in general practitioner fundholding practices.

METHOD

Postal survey of all 13 first-wave fundholders and four of the 13 second-wave fundholders in the former South East Thames Region of the National Health Service in 1995.

RESULTS

Fourteen practices responded. Ten practices had set up at least one medical specialist 'outreach' clinic and 12 at least one paramedical clinic since becoming fundholders. Eight practices reported their arrangements for consultant 'outreach' clinics and ten practices their arrangements for paramedical clinics. Forty-nine per cent of the total medical specialist hours and 46% of total paramedical hours were provided by private practitioners. The largest number of hours provided privately was in gynaecology.

CONCLUSION

This small study identified considerable private provision of fundholders' 'outreach' clinics. However, there is no system in the NHS to monitor the extent of this market, the types of activities undertaken or the relative quality and cost of the services provided.

The health of clients referred to social workers in an intake team

Though numerous reports have strongly argued that there is a need for a closer collaboration between the health and social services, studies investigating the health of clients in contact with the personal social services have been few and limited. This study collected information regarding the physical and mental health of clients referred to social workers in the local authority intake team by means of questionnaires completed by the clients, and a selected sub-sample was also given an interview. Details were also taken regarding the social worker's assessment of health, reasons for referral and their intervention. The results indicated that the proportion of patients with physical or mental illness, or both, were very high and that social workers tended to under-report or under-estimate these illnesses. While there is some suggestion that the social workers were more likely to carry out more interviews with those clients who were ill, either physically or mentally, the contacts between social workers and medical personnel were very limited indeed.