'Abortion' or 'termination of pregnancy'? Views from abortion care providers in Scotland, UK

BACKGROUND

The phrase 'termination of pregnancy' has recently been adopted by a number of British medical institutions as a preferred descriptor of induced abortion. How it is used by abortion care providers is unclear, although the ongoing stigmatisation of abortion may play a role.

METHODS

A mixed methods study of the views of abortion care providers in Scotland, UK. Self-administered anonymous questionnaires were distributed to abortion care providers at a national conference (Scottish Abortion Care Providers). The main outcomes measured were the proportion of respondents reporting that they found the terms 'abortion' and 'termination of pregnancy' to be distressing, and their preferred terminology for use in consultations with women. In-depth interviews were conducted with 19 providers from a single clinic in Scotland to contextualise use of the terminology.

RESULTS

The questionnaire was completed by 90/118 delegates (76%). More respondents indicated they found the term 'abortion' distressing (28%), compared with those who found 'termination of pregnancy' distressing (6%; P<0.0001). Interview participants reported that 'termination of pregnancy' was the default phrase used in consultations. Some respondents stated that they occasionally purposely used 'abortion' in consultations to emphasise the seriousness of the procedure (morally, physically and/or emotionally).

CONCLUSIONS

'Termination of pregnancy' is the most commonly used term to describe induced abortion in patient consultations in Scotland. This and the term 'abortion' appear to play different roles, with the former being used euphemistically, and the latter as a more emphatic term. Further research is warranted to investigate how this interacts with patient care, service provision, and abortion stigma.

A contribution to the discussion on the safety of air weapons

Firearms legislation in the UK stems from the Firearms Act 1968 with its definition of a firearm as a lethal barrelled weapon of any description. The Act allows certain exceptions to be held without licence, most notably air weapons although these are limited by The Firearms (Dangerous Air Weapons) Rules 1969 and related regulations to below 12ft lb (16.3J) for air rifles and below 6ft lb (8.1J) for air pistols. Despite this there are occasional fatalities, typically 1 or 2 each year in the UK, from legally owned air weapons. In the USA there are over 20,000 visits each year to emergency departments due to injuries from air weapons and paintball guns. Despite this, limited research appears to have been carried out into the safety of air weapons and the present study tries to address this. Fresh samples of animal tissue were obtained from an abattoir or butcher and were embedded in ballistic gelatin. Pig heart, lung, liver and shoulder were used. By firing pellets into gelatin alone and into the combination of the gelatin and animal tissue it was possible to compare gelatin as a model for these tissues. The depth of penetration was similar but the residual track appeared to remain more open in the animal tissue. Pellets penetrated completely through the organ, with total penetration of gelatin and organ being typically around 10-15cm. Samples of pig, cow and chicken skin were placed in contact with the gelatin or embedded in the gelatin to simulate the effect of skin on penetration into a body. Chicken skin had no effect, pig skin stopped the pellet and cow skin was perforated by the pellet. If cow skin was embedded in the gelatin there was little effect on the total amount of penetration, but cow skin on the front surface of the gelatin reduced penetration by about 30%. Computed tomography was used to examine the pellet track and to calculate the volume of damage produced. However, due to the similar densities of gelatin and organ a technique had to be developed to differentiate phases. A barium salt paste was applied to outer surfaces and iodine solution or barium nitrate solution containing red food colouring was injected into the pellet track to enhance the contrast of the track. The track through the gelatin tended to enclose itself whereas the track through the organ remained more open, presumably due to the inhomogeneity of the fibrous nature of the tissue. Pellets were also fired at construction materials (wood, plasterboard and brick) and computed tomography used to determine the volume of damage created. Pellets perforated single layers of wood and plasterboard and would embed in a second layer. However, if the two layers were in contact the pellet did not penetrate the first layer. An air rifle pellet could therefore perforate house construction materials, although the resultant kinetic energy would be low and further damage would be limited. Some of the possible physical parameters are discussed that might help predict the degree of damage caused, but from this study it is not possible to define a limit which could be proposed as safe.

Management of menopausal symptoms after cancer and risk-reduction bilateral oophorectomy: a move towards consensus

As more women survive reproductive cancers, menopausal symptoms following treatment can be a significant problem affecting quality of life and wellbeing. Hormone replacement therapy may or may not be contraindicated. Women often receive conflicting information about their management from different specialists. The aim of this study, based in a regional menopause clinic, was to examine referral patterns and symptom profiles of women with cancer or at high risk of cancer; to identify areas of need where a more integrated approach to management might be required; and to reach a local consensus across disciplines involved in the care of these women regarding prescribing of hormonal therapies. A retrospective case record review of all women attending Edinburgh Menopause Clinic for one 12-month period in 2011/2012 for management of cancer-related menopausal symptoms was undertaken. The results of the review were discussed at a multidisciplinary meeting and regional guidance on the management of these women was agreed. There has been an immediate improvement in communication between departments and the quality of information received in referral letters.

The role of desmoglein 2 and E-cadherin in the invasion and motility of human breast cancer cells

Loss of adhesion is a fundamental step in the metastatic cascade. Desmosomal cadherins, Desmoglein (Dsg) and Desmocollin (Dsc) are a novel group of adhesion molecules. Aims were to demonstrate expression of Dsg2 and E-cadherin in breast cancer cells and assess their role in invasion and motility. Immunofluorescence and Western blotting were used to demonstrate expression of Dsg2 and E-cadherin in 3 breast cancer cell lines (MDA MB 231, MCF7 and BT474). Functional studies included cell-cell aggregation, in vitro invasion and colloidal gold phagokinetic tracking assays. All 3 cell lines expressed Dsg2. MCF7 and BT474 cells were E-cadherin positive, MDA 231 was negative. Cell aggregation was reduced, in vitro invasion and motility were increased in Dsg2 or E-cadherin Mab pre-treated cells. Dsg2 present in breast cancer cells may act as a tumour suppressor molecule.

Web-based survey 'Contraception and attitudes to sexual behaviour' completed by women accessing a UK menopause website

BACKGROUND AND METHODOLOGY

Sociodemographic trends mean increasing numbers of new relationships in later life. These trends may not only have health consequences for women and health services but also impact on the targeting of sexual health messages. This study aimed to examine attitudes and knowledge surrounding contraception, sexual health and unwanted pregnancy among those accessing the website www.menopausematters.co.uk. A voluntary online survey was completed.

RESULTS

Survey was completed by 550 respondents. Three hundred and sixty-six women, 94% of whom self-classified as pre- or perimenopausal, had been sexually active with a male partner in the previous four weeks. Commonest contraceptive methods used by perimenopausal and postmenopausal women were condoms, combined oral contraceptive pill (COCP) and male sterilization. Up to 42% of women surveyed were unhappy with their contraception. A total of 27% premenopausal, 32% perimenopausal women and 40% postmenopausal used no contraception. One-third of women were unhappy about this and 19 unplanned pregnancies had occurred. The majority of women were informed regarding COCP use over 35 years, hormone replacement therapy, emergency contraception and ceasing contraception. The majority of women were unaware that more terminations of pregnancy are performed in women over 40 than any other age group per total pregnancies.Almost a third of women were unaware that chlamydia incidence is increasing in older women. Most would use condoms in new relationship.

DISCUSSION AND CONCLUSIONS

Women accessing www.menopausematters.co.uk are well informed about contraception and sexual health. The majority of those accessing the site are sexually active, but many use no contraception, or are unhappy with their chosen method, leaving them vulnerable to unwanted pregnancy or sexually transmitted infection.

Chronic haematoma as a late complication of cosmetic breast augmentation

To our knowledge, a chronic expanding haematoma has not been reported in a patient who received silicone gel breast prostheses for augmentation and never before at an interval as long as 12 years, as in our case. There have been occasional reports of chronic haematoma as complication of implantation of silicone breast prostheses after mastectomy for cancer, presenting 2.5-8 years later.

cAMP-mediated suppression of a Th1 clone associated with an alteration of the intracellular redox environment

We have shown previously that the elevation of intracellular cAMP in antigen or anti-CD3-activated murine Th1 clones in the absence of antigen inhibits antigen-induced proliferation and the production of IL-2 by H2O2-mediated oxidation of p56lck and inhibits antigen-induced production of interferon-gamma by the induction of intracellular nitric oxide. Moreover, activated Th1 clones are resistant to cAMP-induced suppression. These results suggest that the immunosuppression of Th1 cells mediated by elevated intracellular cAMP is associated with an alteration in the intracellular oxidation/reduction environment. Here we report that the culture of an antigen or anti-CD3-activated murine Th1 clone with the adenylcyclase agonist forskolin (FSK) in the absence of antigen reduces the activity of intracellular catalase, and diminishes levels of intracellular reduced glutathione (GSH). Resting cells resistant to cAMP-induced suppression have higher intracellular GSH levels than antigen-activated cells susceptible to cAMP-induced suppression. The results provide further evidence that cAMP-induced suppression of Th1 clones is mediated by profound alterations in the intracellular redox environment and may be used to selectively inactivate Th1 cells activated by antigen.

Performance on tests of frontal lobe function reflect general intellectual ability

Recent studies have indicated that performance on tests of frontal lobe function are highly associated with general intellectual ability (g). Some authors have even claimed that the available evidence does not support a more specific account of frontal lobe function than to provide a general intellectual function for the performance of goal directed tasks. We examined the relationship between performance on the WAIS-R (as a measure of g) and performance on standard tests of frontal lobe function in 123 healthy individuals. Our results demonstrate that in healthy individuals (i) performance on the most popular tests of frontal lobe function shares significant variance, and (ii) a large proportion of that shared variance is highly associated with performance on the Wechsler Adult Intelligence Scales-Revised (WAIS-R), so that the tests are similar to the extent that they measure g. Performance on the Modified Card Sorting Test (MCST), however, is not related to g. The results support the claim that many tests of frontal lobe function measure primarily a non-specific intellectual function but also indicate that some tests, like the MCST, may be assessing more specific cognitive operations.

Differential regulation of T cell receptor-mediated Th1 cell IFN-gamma production and proliferation by divergent cAMP-mediated redox pathways

Culture of an H-2(s)-restricted, bovine myelin basic protein (BMBP)-specific murine Th1 clone with the adenyl cyclase agonist forskolin (FSK) or isobutylmethylxanthine (IBMX), an inhibitor of cAMP catabolism, before culture with anti-CD3 or BMBP and antigen-presenting cells (APC) suppressed antigen or anti-CD3-induced proliferation and production of interferon-gamma (IFN-gamma). Other H-2(s)-derived or H-2(b)-derived clones specific for BMBP or keyhole limpet hemocyanin (KLH) were similarly affected. FSK did not affect the expression of CD4 or the T cell receptor (TCR) but did diminish levels of the phosphorylated (activated) mitogen-activated protein (MAP) kinases early response kinase-1 (ERK-1) and ERK-2. Immunoblotting of lysates from an FSK-treated Th1 clone with antibodies to a carboxy-terminal epitope of p56(lck), a signal transduction enzyme upstream from ERK-1 and ERK2, did not detect p56(lck) unless the lysates were reduced prior to electrophoresis. Immunoblotting of nonreduced lysates with antibodies to an amino-terminal epitope demonstrated p56(lck) with a lower apparent molecular weight, characteristic of oxidized proteins. Reduction restored the detection of p56(lck) by anticarboxy-terminal p56(lck) and to mobilities indistinguishable from controls detected by the antiamino-terminal p56(lck). N-acetylcysteine or catalase prevented FSK-induced suppression of antigen-induced proliferation and the loss of carboxy-terminal epitopes of p56(lck). An inhibitor of cAMP-dependent protein kinase A (PKA) or nitric oxide synthase (NOS) did not affect FSK-induced inhibition of antigen-induced proliferation. In contrast, inhibitors of PKA or NOS, but not catalase, prevented FSK-induced suppression of IFN-gamma production. Moreover, immunoblots of lysates precipitated with anti-p56(lck), phosphotyrosine, or CD4 demonstrated that in FSK-treated, anti-CD3-stimulated cells, p56(lck) is not associated with CD4 zeta chain, nor is p56(lck) or zeta chain phosphorylated. In vitro kinase assays demonstrated that p56(lck) from FSK-treated cells does not have kinase activity. Taken together, the results suggest that an elevation of intracellular cAMP (in the absence of antigen) creates an oxidative environment that oxidizes and inactivates p56(lck) by an H(2)O(2)-dependent, PKA-independent mechanism and inhibits the production of IFN-gamma by an NO, PKA-dependent mechanism. Thus, antigen-induced proliferation and IFN-gamma production in a Th1 clone are controlled separately by different cAMP-dependent, redox-based mechanisms.

Preventing the entrenchment of high expressed emotion in first episode psychosis: early developmental attachment pathways

OBJECTIVE

As part of a strategy to consider the options for preventing the developmental entrenchment of expressed emotion (EE), we examine the early ontogeny of EE in a first-episode sample of individuals with psychosis and its links with the process of adaptation to change.

METHODS

The key relatives of 50 first-episode psychosis patients from two locations were interviewed soon after patient referral and again 9 months later using measures of expressed emotion and loss.

RESULTS

The developmental pathways of components of expressed emotion, particularly criticism and emotional over-involvement, were independent despite having a similar effect on outcome for patients. Initially, high levels of emotional over-involvement were reduced by follow up, with 37% resolving into high criticism. Overall expressed emotion status changed in 28.2% of key relatives (all parental), predominantly from high to low. High emotional over-involvement and low criticism are associated with significantly high levels of perceived loss in relatives. The metamorphosis of emotional over-involvement to criticism was linked to a reduction in perceived loss.

CONCLUSIONS

Expressed emotion is not a stable index in relatives of first-episode psychosis samples. Appraisals of loss by relatives may be driving high emotional over-involvement with implications for family intervention programs. Attachment theory may help to explain some of the processes underlying resistance to change in some of the high-EE behaviours measured by expressed emotion.

Cognitive therapy and recovery from acute psychosis: a controlled trial. 3. Five-year follow-up

BACKGROUND

This paper describes the 5-year outcome of a cohort of patients who had received a cognitive therapy intervention during an acute episode of non-affective psychosis.

METHOD

Thirty-four out of the original 40 patients who had taken part in a randomised controlled trial of a cognitive intervention were assessed, using standardised instruments completed at entry into the study. In the original trial, half the patients received a cognitive therapy programme (CT group) and the other half received recreational activities and support (ATY group).

RESULTS

At follow-up no significant differences in relapse rate, positive symptoms or insight between the groups were found, although the CT group did show significantly greater perceived 'Control over illness' than the ATY group. For individuals who had experienced a maximum of one relapse in the follow-up period, self-reported residual delusional beliefs and observer-rated hallucinations and delusions were significantly less in the CT than in the ATY group.

CONCLUSION

Cognitive therapy applied in the acute phase of a psychotic disorder can produce enduring and significant clinical benefits if experience of relapse can be minimised.

Maternal and child psychological sequelae in paediatric burn injuries

It is a commonly held belief that many children suffer psychological sequelae following burn injury. This six month controlled, prospective, follow up study was designed to investigate psychological sequelae in children and their mothers following paediatric burn injury. The study employed a sample of 40 children with burn injuries, and their mothers with three control groups, each of 40 children and their mothers: an acutely ill group, a fracture group and a non ill/injured group. Measures at initial contact and 6 month follow up included the Child Behaviour Checklist and the Hospital Anxiety and Depression Scale. The results demonstrated higher initial maternal anxiety scores in the burn, compared to the fracture and non ill/injured groups, which remained comparatively high 6 months later even though they decreased over time. Children with burn injuries, of the type included in this study, did not appear to develop significant psychological or behavioural sequelae. Following paediatric burn injury mothers appear to be at higher risk than children for developing psychological sequelae, which may have longer term implications for the child's outcome such as affecting compliance with treatment.

Mental health care for Asian, black and white patients with non-affective psychoses: pathways to the psychiatric hospital, in-patient and after-care

BACKGROUND

This UK-based study compares the pathways to the psychiatric hospital and the provision of in-patient and after-care for Asian, black and white patients with non-affective psychoses.

METHODS

Two overlapping samples of 120 patients, 40 from each ethnic group, were drawn; one on admission and the other at discharge. In addition to socio-demographic data, details were obtained on the pathways to care and the in-patient episode. An assessment of needs and service provision was undertaken 3 months post-discharge. Patient satisfaction was ascertained at each stage.

RESULTS

Asian and especially black patients experienced more complex pathways and had higher levels of both involvement with the police and compulsory detention than their white counterparts. They were less likely to perceive themselves as having a psychiatric problem or as needing to go into hospital and expressed less satisfaction with the admission process. Black patients, as compared to Asian but especially white patients, were more often detained in hospital against their will, confined to the ward and treated within a secure environment. However, there were few differences in satisfaction with hospital care. Likewise, perceptions of unmet need, provision of after-care and satisfaction with services were similar across the ethnic groups.

CONCLUSIONS

The implications of these findings are discussed. The potential of early intervention programmes and home treatment services to address the ethnic differentials identified in this study merit consideration.

Mental health of elderly Asians in the UK

Elderly Asians constitute a small proportion of the population compared to elderly whites [corrected], but this is growing rapidly. They share many of the disadvantages of the white elderly, as well as being non-white and alien. Many elderly Asians have now accepted that they will stay in the UK for good, which may contribute to increased stability in their mental health.

A mediational model of quality of life for individuals with severe mental health problems

BACKGROUND

Despite the increasing importance of quality of life in the mental health field, the theoretical conceptualization of the construct remains poorly developed. A proposed mediational model of quality of life, which links subjective quality of life with self-related constructs, is examined with a group of long-term psychiatric hostel residents. The present study aims to develop a measure of quality of life based on the proposed model, to explore the data and their implications for service development and finally to conduct a preliminary analysis of the model's predictions.

METHODS

A cross-sectional research design was employed. Quality of life interviews, using a modified version of Lehman's Quality of Life Interview, were carried out with 54 psychiatric residents in Greece. The model's predictions were examined by using a series of regression analyses.

RESULTS

The results indicate that perceived improvements in lifestyle, greater autonomy and positive self-concept are significantly and directly associated with better quality of life. In contrast, a direct relationship between objective indicators and subjective quality of life was not found.

CONCLUSIONS

The traditional two-part quality of life model that includes objective indicators of life circumstances and subjective indicators is extended to included the constructs of self-concept and perceived autonomy. The present extended mediational model of quality of life for individuals with long-term mental health problems appears to have important implications for the planning and delivery of mental health programmes.

Seasonal variations in hospital admissions for affective disorders by gender and ethnicity

Hospital admission statistics for depression and mania have shown significant seasonal patterns. The present investigation was conducted to establish the pervasiveness of the impact of seasons on mood disorder presentation at Birmingham (52 degrees North) by gender and ethnicity. Non-mood disorder admissions were examined as a control to determine the specificity of any seasonal variation to affective illness. Case notes for 992 admissions, during January-December 1995 inclusive, to an inpatient unit were reviewed retrospectively. Admission data were broken down by gender and into three ethnic groups: Asian, white and black. Seasonality in admissions for depression, bipolar disorder and non-mood disorders was tested by gender and ethnicity. Admission frequencies for depression showed significant seasonal pattern, with the incidence of depression being highest in winter. Total admissions, bipolar and non-mood disorders did not show any significant seasonal variability. A gender effect was evident on seasonality of admissions for affective illness, with significant winter peak for depression and summer peak for bipolar disorder in women only. The Asian group was the only ethnic group that showed significant seasonal variation in depression, with a greater number of depressive episodes in winter. Environmental variables were related significantly to the incidence of mood disorders. Specific seasonal effect for affective illness was evidenced by the non-existence of seasonality in other psychiatric disorders. The reverse seasonal pattern for depression and mania suggests a maladaptive response of vulnerable individuals to specific functions of seasons.

The role of nitric oxide in cancer. Improved methods for measurement of nitrite and nitrate by high-performance ion chromatography

The short lifetime of nitric oxide (NO) in vivo impedes its quantitation directly; however, the determination of nitrite and nitrate ions as the end-products of NO oxidation has proven a more practical approach. High-performance ion chromatographic analysis of nitrite in biological fluids is hampered by the large amount of chloride ion (up to approximately 100 mmol/l) which results in insufficient peak resolution when utilizing conductimetric detection. Analysis of both anions in small sample volumes is also constrained by the need to minimise sample handling to avoid contamination by environmental nitrate. We report a means to remove Cl- ions from small sample volumes using Ag+ resin which facilitates quantitation of either nitrite and nitrate anions in biological samples, using silica or polymer based ion-exchange resins with conductimetric or electrochemical and spectrophotometric detection. Including a reversed-phase guard column before the anion-exchange guard and analytical column also greatly extends column lifetime.

Undetected gynaecological disorders in women with renal disease

Women with chronic renal disease (CRD) who are on dialysis or have a functioning renal transplant are typically stoical in their attitude towards other health problems. We undertook a prospective study of 100 women with CRD to assess the prevalence of gynaecological disorders in this group of patients. Assessment included the measurement of follicle stimulating hormone, luteinizing hormone, prolactin and oestradiol concentrations, cervical cytology and a pelvic ultrasound scan. We found that gynaecological problems are highly prevalent and frequently unrecognized. Of these women, 58% had a menstrual disorder, with uncontrolled menorrhagia being a significant problem when it aggravated the chronic anaemia of renal disease, and 35% were menopausal, including seven women under the age of 40 years. Menopausal symptoms were undertreated. We identified a 14-fold increase in premature ovarian failure secondary to CRD and the use of cyclophosphamide therapy. In all, 22% of the women were subfertile and 10% had an abnormal smear, with cervical dyskariosis being significantly increased because of long-term immunosuppression. Contraceptive advice had often been absent or inappropriate. We conclude that formal gynaecological review should be routinely available for women with CRD.

Seasonal changes in affective state in samples of Asian and white women

Seasonality of the affective state has been reported to vary in direct proportion to latitude in temperate regions. The frequency of seasonal affective disorder (SAD) and the severity of the symptoms associated with it have been reported to be greater in higher than in lower latitudes. In addition, recent research has suggested a genetic loading for SAD. Most of the research on the seasonality of affect has been done in high latitude areas, seasonal mood cycles have been infrequently investigated in tropical areas, and no study has so far measured and compared seasonal changes in affect and behaviour in indigenous and populations non-indigenous to high latitudes. To rule out the biases associated with retrospective designs, a prospective longitudinal study was designed to investigate seasonal mood variations in indigenous white and non-indigenous Asian populations. Since previous research has indicated the excessive vulnerability of women to winter depression, it was decided to measure seasonality of the affective state only in women. To examine the relative effects of genetic predispositions and physical environment, the Asian group was further divided into "Asian" and "Asian-British". The former group comprised women who were living in England but who had been born and had spent considerably more time in their country of origin, while the latter group consisted of women who were born in England and who had lived there all their lives. The three groups of 25 women each were matched for age and socio-economic status, and were interviewed every month for 1 year using the Hospital Anxiety and Depression Scale (HAD), a Behavioural Change Inventory (BCI), the Ladder Scale of General Well-being (LSW) and a Monthly Stress Inventory (MSI). One retrospective scale was administered at the end of the study year to compare the extent of seasonal change in affect with that on the HAD-depression subscale. The results showed that seasonal depression peaked in winter in all three groups, with the incidence of winter depression being highest in the Asian group. Seasonal changes on several dimensions of behaviour were in the direction of winter depression for all three groups. States other than depression (anxiety and general well-being) did not show any seasonal variation. Hours of daylight was found to be the best predictor of seasonal variation in mood among environmental and psychosocial variables. There was no evidence to support a genetic hypothesis for SAD.

Elevation of intracellular cyclic AMP induces an anergic-like state in Th1 clones

Because elevated intracellular cAMP suppresses T cell receptor (TCR)-mediated effector activity and/or proliferation in response to antigen but does not always affect IL-2-stimulated proliferation, the effects of cAMP on a T lymphocyte response to antigen resemble antigen-induced anergy. To test the hypothesis that elevated cAMP induces anergy in T lymphocytes, we have precultured murine Th1 clones responsive to porcine myelin basic protein (PMBP) with dibutyryl cyclic AMP (dbcAMP) or forskolin and subsequently removed the dbcAMP or forskolin and measured the proliferative response of the clones to antigen and antigen-presenting cells (APC) in the presence or absence of exogenously added interleukin-2 (IL-2). Cells precultured with dbcAMP or forskolin for 3 days did not proliferate or produce IL-2 in response to antigen and APC, but did proliferate to antigen and APC in the presence of IL-2. Cells that had not been stimulated recently with antigen/APC or IL-2 were not affected by dbcAMP, while cells stimulated recently with antigen/APC and IL-2 were susceptible to the anergizing effect of dbcAMP. These observations support the hypothesis that elevation in intracellular cAMP in antigen-activated Th1 clones, prior to subsequent culture with antigen, induces a state of anergy.

Cognitive therapy and recovery from acute psychosis: a controlled trial. I. Impact on psychotic symptoms

BACKGROUND

The application of cognitive therapy (CT) to psychosis is currently being developed in the UK. This paper reports a trial of CT in acute psychosis with the objective of hastening the resolution of positive symptoms and reducing residual symptoms.

METHOD

Of 117 patients with acute non-affective psychosis, 69 satisfied inclusion criteria and 40 proceeded to stratified randomisation. The experimental intervention involving individual and group CT was compared with a group receiving matched hours of therapist input providing structured activities and informal support; routine pharmacotherapy was provided by clinicians blind to group allocation. Patients were monitored weekly using self-report and mental state assessments during admission and over the subsequent nine months.

RESULTS

Both groups showed a decline in positive symptoms but this was more marked in the CT group (P < 0.001). At 9 months 5% of the CT group, v.56% of the control group, showed moderate or severe residual symptoms.

CONCLUSION

CT appears to be a potent adjunct to pharmacotherapy and standard care for acute psychosis. Issues concerning internal and external validity of the study and opportunities for further research are discussed.

Cognitive therapy and recovery from acute psychosis: a controlled trial. II. Impact on recovery time

BACKGROUND

A trial of CT in acute psychosis conducted by the authors has shown a significant impact on the rate and degree of recovery of positive symptoms, the focus of the intervention. This paper seeks to determine whether these effects generalise to other features of acute psychosis including dysphoria, insight and "low level' psychotic thinking which were not directly targeted.

METHOD

Measures of dysphoria, insight and psychotic thinking were taken over a six-month period following presentation for acute psychosis. Using survival analysis, time to recovery from psychosis using three definitions of increasing stringency was compared between the CT and control group.

RESULTS

CT was associated with a 25-50% reduction in recovery time depending on the definition used.

CONCLUSION

The impact of the CT intervention extended beyond positive symptoms to include insight, dysphoria and "low level' psychotic thinking. Nevertheless this kind of "clinical' recovery required a median of 20 weeks to complete. Implications for clinical models of acute care are discussed.

Seasonal changes in affective state measured prospectively and retrospectively

BACKGROUND

The study was designed to investigate whether seasonal mood and behavioural changes are detectable prospectively in a non-clinical population in the way they have been reported in retrospective studies. The specificity of any seasonal fluctuation in affective state was also investigated by measuring anxiety as well as depression.

METHOD

To measure seasonal fluctuations in affect and behaviour prospectively, 25 women were interviewed every month for one year using four scales (depression, anxiety, stress, and behavioural change). Retrospective accounts of mood and behaviour at the end of the year were collected with the Seasonal Pattern and Assessment Questionnaire (SPAQ).

RESULTS

Seasonal depression peaked in winter as did atypical behaviour when measured either prospectively or retrospectively, but the difference between winter and summer was much more pronounced in the retrospective data. No seasonal effect was found for anxiety or psychosocial stressors.

CONCLUSIONS

The results obtained by retrospective techniques have limited reliability. In the future, more prospective studies with unbiased, standardised instruments are recommended to measure seasonal variations in affect and behaviour.

Drinking patterns of black and white men in the west Midlands

The limited amount of evidence available from mortality statistics, mental hospital in-patient admission rates and community surveys appears to indicate that people of African-Caribbean origin resident in Britain have fewer alcohol-related problems than the white population. However, there are no systematic data on the normal drinking habits of random and representative samples of the black population of Britain, or the true extent of alcohol-related problems in the whole population. A survey of the drinking habits and alcohol-related problems of random samples of 200 black men and 170 white men from the Birmingham and Wolverhampton areas is reported. Black men were much less likely to report regular drinking and to report drinking large amounts of alcohol. They were far less likely to have got drunk in the past year, and scored lower on most items of an Alcohol Problems Scale. Age was the only demographic variable associated with drinking levels in both groups, and the link was more tenuous in the black than the white group. There were no generational differences found. Religious observance and belonging to a Pentecostal Church were found to be major differences between the black and white groups, and strongly associated with moderation in relation to alcohol.

Women's knowledge of emergency contraception

BACKGROUND

More widespread use of emergency contraception could help to reduce the number of unwanted pregnancies.

AIM

The objective of this study was to assess women's knowledge of emergency contraception.

METHOD

A questionnaire was distributed to 1290 women aged between 16 and 50 years attending 14 general practice surgeries in London over a two-week period in 1990.

RESULTS

The response rate was 70%. Over three quarters of the women had heard of emergency contraception; these were mainly women who used contraception, who had higher educational qualifications or who were not Muslim. Women who were the most likely to need and to use emergency contraception--those using barrier methods--had no more accurate knowledge than women using any other method of contraception. Only 53% of barrier method users knew emergency contraception could be used as a backup when other methods failed. Only one fifth of women had heard about this method from their general practitioner or any other health professional, while half had obtained their information from the media.

CONCLUSION

These results suggest that including information on emergency contraception in consultations with users of barrier methods of contraception is a small step which general practitioners and practice nurses could take to increase the use of emergency contraception.

The needs of high and low expressed emotion families: a normative approach

Comparison of the needs and characteristics of relatives classified as high and low expressed emotion (EE) across a range of measures including social functioning and indices of stress and family burden revealed that high EE relatives reported higher levels of disturbed behaviour, subjective burden, and perceived themselves as coping less effectively. Individuals from high-EE households were more impaired in terms of social functioning, particularly in terms of independence and interpersonal functioning. No difference in overall knowledge about schizophrenia was observed between high and low EE relatives, although high EE relatives possessed more information about hospital procedures. Analysis of needs assessment data, based on a normative approach to need, revealed that two-thirds of high EE relatives, as against one-third of low EE relatives had high needs in at least one or more of the following five areas: knowledge about schizophrenia, subjective burden, personal stress, behavioural disturbance and perceived coping. No low EE relative had high needs on all five criteria. The implications of the results for the meaning and genesis of EE and for service provision are considered.

The influence of ethnicity and family structure on relapse in first-episode schizophrenia. A comparison of Asian, Afro-Caribbean, and white patients

There is overwhelming evidence that the outcome for people with schizophrenia in Western industrialised countries is inferior to that of those living in the Third World. Extended family structures, greater opportunities for social reintegration, and more positive constructions of mental illness have been offered as possible explanations for this effect. The Asian community in the UK retains many of these features as well as strong links with native cultures of origin. The issue arises as to whether similar differences in outcome may be observed in the UK. An exploratory study was undertaken, examining the early progress of schizophrenia in a first-episode sample (n = 137), and based on systematic examination of case-note data. A lower rate of relapse/readmission in the first 12 months after discharge was found in the Asian (16%) as compared with white (30%) and Afro-Caribbean (49%) patients. Available evidence suggested that speed of access to care, living with a family, and employment may account for this effect. Medication compliance may have contributed to differences in relapse between white and Afro-Caribbeans but was not a factor influencing the low rate among Asians. The limitations and strengths of case-note studies are discussed at length, and it is concluded that a prospective study is warranted and would be highly instructive.

Specific and non-specific effects of educational intervention for families living with schizophrenia. A comparison of three methods

Three methods of delivering an educational intervention to families living with a schizophrenic relative were compared in terms of their efficacy in improving understanding and promoting family and patient well-being. Relatives receiving education in a group acquired more information than relatives receiving information by post or on video, but these differences were not maintained at six-month follow-up. The inclusion of homework assignments did not significantly affect gains in knowledge or any of the non-specific effects observed. The intervention overall led to considerable gains in knowledge, increased optimism concerning the family's role in treatment, and reductions in relatives' stress, which were maintained at follow-up. Fear was reduced in the short-term. Significant improvements in social function were observed at follow-up. The results suggest that the delivery of information, rather than the mode of delivery, is the crucial element in the intervention; however, the additional contextual factors operating in a group may be important if the full potential of education is to be realised.

The effects of physical activity and exercise training on psychological stress and well-being in an adolescent population

To determine whether participating in physical activity affects psychological well-being in an adolescent population, 147 adolescents completed self-reports of exercise and psychological stress and well-being. Analysis revealed that those who reported greater physical activity also reported less stress and lower levels of depression. Adolescents who experienced a higher incidence of life events also demonstrated a strong association between stress and anxiety/depression/hostility. To investigate the effects of exercise training on psychological well-being, adolescents were assigned to either high or moderate intensity aerobic training, flexibility training or a control group. The training groups met twice per week for 25-30 min. Aerobic fitness levels, heart rate, blood pressure and self-report of stress and well-being were measured prior to and following 10 weeks of training. Post-training fitness measures confirmed the effectiveness of the high intensity aerobic exercise and between groups differences for physiological and some psychological measures were found. Subjects undergoing high intensity exercise reported significantly less stress than subjects in the remaining three groups. The relationship between stress and anxiety/depression/hostility for the high intensity group was considerably weakened at the end of the training period. For the remaining subjects, however, this relationship was, if anything, strengthened. This experiment provides evidence to suggest that in an adolescent population, high intensity aerobic exercise has positive effects on well-being.

Selection of children with cerebral palsy for conductive education and the characteristics of children judged suitable and unsuitable

The method of selection of children for conductive education and their characteristics were studied at the Birmingham Institute. A comparison group allowed evaluation of those judged unsuitable for conductive education. It was found that only approximately 35 per cent of children with cerebral palsy are suitable for conductive education, although those accepted have a wide range of abilities; a wide range of conditions make children unsuitable for conductive education; and the majority of parents with potentially suitable children do not seek conductive education.

The Social Functioning Scale. The development and validation of a new scale of social adjustment for use in family intervention programmes with schizophrenic patients

Social functioning as an outcome variable in family interventions with schizophrenic patients has been a relatively neglected area. The requirements of a scale of social functioning to measure the efficacy of family interventions include: the measurement of skill/behaviour relevant to the impairments and the demography of this group; the ability to yield considerable information with an economy of clinical time; and the establishment of 'comparative' need through comparison between subscales and with appropriate reference groups. Results from three samples show that the Social Functioning Scale is reliable, valid, sensitive and responsive to change.

Families coping with schizophrenia: coping styles, their origins and correlates

An analysis of the coping styles adopted by relatives of schizophrenic patients has been identified by many reviewers as essential to an understanding of the complex interactions between patient and caregiver and to the origins of relatives' expressed emotion (EE). This study reports a taxonomy of coping behaviour derived from interviews with relatives of schizophrenic patients. It was found that relatives adopted broad styles of coping across all areas of patients' behaviour change. Relationships were uncovered between the styles and (a) relatives perceived control, burden and stress, (b) patients' social functioning, severity of behavioural disturbance and progress of the illness. It is suggested that advising relatives of changes in their coping styles in the course of family intervention must be tempered by an understanding of their origins in patients' behaviour. Further research is recommended to identify the coping styles associated with the high EE/low EE research classification.

The drinking habits of Sikh, Hindu, Muslim and white men in the West Midlands: a community survey

Men born in India but living in Britain have higher than expected treated prevalence rates of alcohol-related disorders. A community survey of random samples of 200 each of Sikh, Muslim and Hindu men and 200 white English-born men, matched for age, were interviewed using a structural questionnaire containing a retrospective drinking diary. Sikhs were most likely to be regular drinkers followed by whites and Hindus. The very few Muslim men who drank consumed the most alcohol on average. The frequently reported pattern of an inverse relationship between drinking and age was found for white men but not among Sikhs and Hindus. In both these groups older men reported consuming more alcohol than did young men. However, age was confounded with generation: heavier levels of consumption were reported by Sikhs and Hindus born in India than by Sikhs and Hindus born in Britain. Among regular drinkers Sikhs had higher average Alcohol Problem Scale Scores than did white men or Hindus. The highest average scores were recorded for the (few) Muslim regular drinkers (who also consumed the most alcohol). A clear association with religious observance was found for all three Asian groups and for the white men. No religious Muslims drank at all, and a relatively small proportion of the other groups who were regular church/Temple attenders drank regularly.

The child-rearing values of Asian and British parents and young people: an inter-ethnic and inter-generational comparison in the evaluation of Kohn's 13 qualities

As part of a larger survey concerned with attitudes and experiences of two generations of Asian-British and of native white British, respondents were asked to rate the three most desirable of Kohn's (1969) 13 values in child rearing. Sampling in urban areas with large Asian populations provided a total sample of relatively homogeneous socio-economic status; thus, the class comparisons which informed Kohn's original thesis were less relevant. Comparisons were made on the basis of generation and of ethnicity. It was found that Asians value conformity more and self-direction less than the British, and that this difference is considerably more pronounced in the older than in the younger generation. Extent of traditionalism in family processes was related to evaluations. For Asian young people only, extent of assimilation with British life was related to evaluation made.