Which is more important for outcome: the physician's or the patient's understanding of a health problem? A 2-year follow-up study in primary care

ObjectiveWe sought to examine (1) whether the patients' and the family physicians' (FPs') beliefs about the nature of a health problem predict health outcomes and (2) whether the FPs were aware of their patients' beliefs.MethodsA 2-year follow-up study of 38 FPs and 1131 patients presenting with well-defined physical disease (n=922) or medically unexplained symptoms (MUS) (n=209) according to the FPs was conducted. Before the consultation, patients categorized their health problem as being either physical or both physical and psychological. After the consultation, the FPs judged their patients' understanding of the health problem. Outcome measures were (1) patient satisfaction (seven-item Patient Satisfaction Consultation Questionnaire), (2) self-perceived mental and physical health (component summaries of the Medical Outcome Study's Short Form: SF-36) and (3) health care use extracted from patient registers.Main resultsPatients with MUS according to the FPs and patients who believed that the nature of their health problem was both physical and psychological had higher health care use and worse self-rated health than patients in cases where both the FP and the patient had a physical understanding. Patients presenting MUS were more dissatisfied with the consultation than patients with well-defined physical disease.Overall, the FPs' perceptions of their patients' understanding were accurate in 82% of the consultations, but when the patients had a both physical and psychological understanding of their health problem, the FPs were right in only 26% of the consultations.ConclusionsBoth FPs' diagnoses and patients' beliefs predict important health outcomes such as patient satisfaction, use of health care and self-rated health.     

What do predict anxiety and depression in breast cancer patients? A follow-up study

Introduction  

Psychological adjustment following cancer occurrence remains a key issue among the survivors. This study aimed to investigate psychological distress in patients with breast cancer following completion of breast cancer treatments and to determine its associated factors.     

Does a coexisting anxiety disorder predict persistence of depressive illness in primary care patients with major depression?

We assessed whether a coexisting anxiety disorder predicts risk for persistent depression in primary care patients with major depression at baseline. Patients with major depression were identified in a 12-month prospective cohort study at a University-based family practice clinic. Presence of an anxiety disorder and other potential prognostic factors were measured at baseline. Persistent depressive illness (major depression, minor depression, or dysthymia) was determined at 12 months. Of 85 patients with major depression at baseline, 43 had coexisting anxiety disorder (38 with social phobia). The risk for persistent depression at 12 months was 44% greater [Risk Ratio (RR) = 1.44, 95% confidence interval (CI) 1.02-2.04] in those with coexisting anxiety. This risk persisted in stratified analysis controlling for other prognostic factors. Patients with coexisting anxiety had greater mean depressive severity [repeated measures analysis of variance (ANOVA), p < 0.04] and total disability days (54.9 vs 19.8, p < 0.02) over the 12-month study. Patients with social phobia had similar increased risk for persistent depression (RR = 1.40, 95% CI 0.98-2.00). A coexisting anxiety disorder indicates risk for persistent depression in primary care patients with major depression. Social phobia may be important to recognize in these patients. Identifying anxiety disorders can help primary care clinicians target patients needing more aggressive treatment for depression.     

Do alexithymic traits predict illness?

The common theoretical speculation that alexithymic personality characteristics (impoverished fantasy life and difficulty expressing feelings verbally) lead to psychosomatic disease was tested in a sample of 181 men. Unlike previous investigations, this study used a measure of alexithymic characteristics taken at least 1 year before any of the men became ill. Comparisons were made of the premorbid MMPI alexithymia scale scores of groups of men who remained well for 10 years or within 10 years developed either physical illness (cancer or benign tumors), "classical" psychosomatic disease (hypertension or gastrointestinal ulcers), or psychiatric disorder (schizophrenia). Results did not support the notion that alexithymia leads to illness onset. There were no significant differences among the groups in their premorbid alexithymia scores. Furthermore, the groups did not differ in the percentage of individuals labeled alexithymic with the use of previously established cut-off points. Although the findings cast doubt on alexithymia as a cause of illness, they do not conflict with the idea that alexithymia can result from the stress of disease or that this type of personality configuration may lead to a decreased response to treatment and a prolonged course of illness.     

Medical outcome in epilepsy patients of young adulthood—A 5-year follow-up study

The appearance of new anti-epileptic drugs (AED) during the last decade has provided neurologists and their patients with a greater choice, but the proof for their superiority over traditional AEDs is sparse, especially their use in adolescence and young adulthood. We studied a group of young adults (18–27 years) with epilepsy and compared their situation in 2004 with those 5 years earlier.Materials and methodsThe participants (n = 97) answered questionnaires regarding seizure-frequency, AED, side-effects and quality-of-life. Information was also taken from medical records.ResultsThe use of new generation AEDs increased during the 5-year study period, particularly among women. However seizure frequency had not changed significantly over time, and compared to men the effectiveness in controlling seizures was lower in women. The participants reported normal quality-of-life (QOL), which may indicate that the increase in number of AEDs to choose from actually improved the situation for these young adults with epilepsy. Frequency of seizures and cognitive side-effects of AEDs were associated with a lower QOL.ConclusionsMore women than men seem to be treated with new AEDs, and that the increase in use of new AEDs does not reduce seizure frequency in young adulthood. The effectiveness in controlling seizures seems to be lower in women in the age group studied. Further studies are required to better understand how epilepsy related factors interact.     

Do illness perceptions and mood predict healing time for burn wounds? a prospective, preliminary study

Some burn wounds take longer to heal than others, but this cannot be fully explained by physical factors such as burn size and depth. Research interest has therefore focussed on the potential contribution of psychological factors, such as perception of the burn and distress, to the wound healing process.

Objectives

Using the framework of Leventhal's Common-Sense Model, we investigated whether patients’ perceptions of their burn wounds and distress contributed to healing time, and whether this was via the mediating role of adherence to treatment recommendations.

Method

Seventy-two adult burn-injured outpatients completed questionnaire measures of burn perceptions (Brief Illness Perception Questionnaire), distress (Hospital Anxiety and Depression Scale), trauma symptoms (Impact of Event Scale-Revised) and appearance concerns (Derriford Appearance Scale-24). Burn characteristics, healing time and adherence data were taken from clinic notes.

Results

Distress, trauma symptoms and appearance concerns were positively correlated with negative burn perceptions. In regression analysis, burn perceptions added significantly to the prediction of burn healing time after age, medical factors and burn characteristics had been controlled for. Adherence measures were not significantly correlated with burns perceptions.

Conclusions

Our findings suggest that patients’ perceptions of their burns contribute to healing time. Further research on the mechanisms of this association is warranted.     

Do ictal EEG characteristics predict treatment outcomes in schizophrenic patients undergoing electroconvulsive therapy?

Objective: The aim of this study is to investigate the relationship between features of electroencephalography (EEG), including seizure time, energy threshold level and post-ictal suppression time, and clinical variables, including treatment outcomes and side-effects, among schizophrenia inpatients undergoing electroconvulsive therapy (ECT). Method: This is a naturalistic follow-up study on schizophrenia patients, diagnosed using DSM-IV-TR criteria, treated by a psychosis inpatient service. All participants completed the Brief Psychiatric Rating Scale (BPRS), the Global Assessment of Functioning (GAF) scale, the Frontal Assessment Battery (FAB) and a Data Collection Form. Assessments were made before treatment, during ECT and after treatment. Findings: Statistically significant improvements in both clinical and cognitive outcome were noted after ECT in all patients. Predictors of improvement were sought by evaluating electrophysiological variables measured at three time points (after the third, fifth and seventh ECT sessions). Logistic regression analysis showed that clinical outcome/improvement did not differ by seizure duration, threshold energy level or post-ictal suppression time. Discussion and conclusion: We found that ictal EEG parameters measured at several ECT sessions did not predict clinical recovery/outcomes. This may be because our centre defensively engages in “very specific patient selection” when ECT is contemplated. ECT does not cause short-term cognitive functional impairment and indeed improves cognition, because symptoms of the schizophrenic episode are alleviated.     

Physical activity counseling in primary care and patient well-being: Do patients benefit?

Background: Promoting physical activity is an important public health strategy for long-term reductions in incidence or severity of clinical disease. Benefits to health-related quality of life (HRQL) and subjective well-being may be as important and take less time to accrue.Purpose:We examined the HRQL benefits of a social-cognitive-theory-based intervention of the Activity Counseling Trial (ACT), both directly in terms of changes in physical fitness and indirectly from increased self-efficacy associated with the intervention.Methods: In ACT, 395 female and 479 male inactive patients ages 35 to 75 years were randomized to one of: physician advice, advice plus behavioral counseling during primary care visits, or advice plus behavioral counseling that also included telephone contact and behavioral classes. Participants were assessed at baseline, 6 months, and 24 months. HRQL was assessed as perceived quality of life, perceived stress, depression, and general health. Satisfaction with function and appearance, self-efficacy, and social support were also assessed.Results: At 24 months women who received counseling or assistance had significant reductions in daily stress and improvements in satisfaction with body function compared to those receiving advice only. Men had reductions in daily stress across all treatment arms. These results mirrored V0₂max changes observed per group. Change in barriers self-efficacy was significantly associated with reductions in daily stress at 24 months.Conclusions: Patient benefit from ACT intervention was mediated by enhanced cardiorespiratory fitness and by barriers self-efficacy.     

Do the same factors predict outcome in schizophrenia and non-schizophrenia syndromes after first-episode psychosis? A two-year follow-up study

ObjectiveThe aim of this two-year longitudinal study was to identify the best baseline predictors of functional outcome in first-episode psychosis (FEP). We tested whether the same factors predict functional outcomes in two different subsamples of FEP patients: schizophrenia and non-schizophrenia syndrome groups.MethodsNinety-five patients with FEP underwent a full clinical evaluation (i.e., PANSS, Mania, Depression and Insight). Functional outcome measurements included the WHO Disability Assessment Schedule (DAS-WHO), Global Assessment of Functioning (GAF) and Clinical Global Impression (CGI). Estimation of cognition was obtained by a neuropsychological battery which included attention, processing speed, language, memory and executive functioning.ResultsGreater severity of visuospatial functioning at baseline predicted poorer functional outcome as measured by the three functional scales (GAF, CGI and DAS-WHO) in the pooled FEP sample (explaining ut to the 12%, 9% and 10% of the variance, respectively). Negative symptoms also effectively contributed to predict GAF scores (8%). However, we obtained different predictive values after differentiating sample diagnoses. Processing speed significantly predicted most functional outcome measures in patients with schizophrenia, whereas visuospatial functioning was the only significant predictor of functional outcomes in the non-schizophrenia subgroup. Conclusions: Our results suggest that processing speed, visuospatial functioning and negative symptoms significantly (but differentially) predict outcomes in patients with FEP, depending on their clinical progression. For patients without a schizophrenia diagnosis, visuospatial functioning was the best predictor of functional outcome. The performance on processing speed seemed to be a key factor in more severe syndromes. However, only a small proportion of the variance could be explained by the model, so there must be many other factors that have to be considered.     

Do patients with schizophrenia ever show periods of recovery? A 15-year multi-follow-up study

Contrary to older views, with modern treatment some or many patients with schizophrenia may show intervals of recovery. The current 15-year prospectively designed follow-up research comparing schizophrenia patients with other types of psychotic and nonpsychotic patients studied how many schizophrenia patients ever show intervals of recovery. Two hundred seventy-four early young psychiatric patients from the Chicago Followup Study, including 64 schizophrenia patients, 12 schizophreniform patients, 81 other psychotic patients, and 117 nonpsychotic patients, were assessed as inpatients and then reassessed 5 times over 15 years. Patients were evaluated for recovery for 1 or more years using an operational definition of recovery. Cumulatively, over the 15-year period slightly over 40% of patients with schizophrenia showed 1 or more periods of recovery. However, schizophrenia is still a relatively poor outcome disorder, showing poorer courses than other types of psychotic and nonpsychotic disorders (p < .001). Most schizophrenia patients did not show the severe social isolation often described prior to the modern treatment era. Schizophreniform patients tended to show more favorable outcomes than schizophrenia patients. Over 50% of the schizophrenia patients did not have a disorder that was chronic and continuous. Rather, their disorder was episodic, although for many more vulnerable and less resilient schizophrenia patients the episodes were more frequent and severe, with slower recovery.     

Can we predict benign multiple sclerosis? Results of a 20-year long-term follow-up study

Benign multiple sclerosis (MS) is a discussed clinical entity, with variable reported prevalence (6–64%) requiring at least 5–10 years of clinical observation. Moreover, many benign patients progress with time becoming no longer benign (NLB). The objective of this study is to compare benign MS patients (EDSS ≤3, 10 years from disease onset) who still fulfilled the definition at 20 years to those NLB. In our retrospective study based on Ottawa Hospital MS Clinic database, 175 benign patients fulfilled the inclusion criteria (clinically definite MS, EDSS ≤3 at 10 years, disease onset from 1983 to 1993, and clinical assessments performed at 10 ± 1 and 20 ± 1 years from onset). Out of the identified patients, 66.3% remained benign at 20 years; however, by changing the definition for benign to EDSS ≤2 or ≤1 at 10 years, they increased to 71.9 and 81.6%, respectively. Female sex, EDSS ≤1 at 10 years, and a pure sensory onset were associated with a benign course, while a pure motor onset with an NLB condition. According to multivariate analysis, an EDSS ≤2 at 10 years predicted a long-term benign course. Our study questions the current definition of “benign” MS, suggesting a more stringent EDSS cutoff at 10 years to predict long-term benign prognosis.     

Do epileptic seizures predict outcome in patients with oligodendroglioma?

Zonisamide (ZNS) is an antiepileptic drug (AED) with multiple putative mechanisms of action. It is chemically unrelated to other AEDs. It has been available in Japan since 1989 but was only licensed in Europe in 2005. Its efficacy and tolerability have been shown in several randomised controlled trials, but large studies on long-term performance in Western clinical practice are scarce. We assessed a large cohort of consecutive people who started ZNS at a tertiary epilepsy referral centre, from June 2005 to July 2009. Forty-six percent of the 417 people included were still taking ZNS at last follow-up, with an estimated retention rate at three years of 30%. Almost one third of the population reported a period of improvement in terms of seizure reduction of at least six months duration whilst on ZNS. Sixteen people became seizure free for at least six months and seven of these were seizure free for one year or more. Adverse events occurred in 58%, frequently CNS-related. People on three or more AEDs and people starting zonisamide at 25mg daily rather than 50mg or more, were more likely to discontinue ZNS. Retention rates for ZNS were similar to those previously reported, and comparable to lamotrigine, topiramate, pregabalin, higher than gabapentin, and lower than levetiracetam.     

Do illness perceptions predict attendance at cardiac rehabilitation and quality of life following myocardial infarction?

OBJECTIVE: The aim of this study was to examine the extent to which illness perceptions predict attendance at cardiac rehabilitation and quality of life following myocardial infarction (MI). METHODS: The illness perceptions of 194 MI patients were assessed whilst the patients were still in hospital following an MI. The mean age was 63.3 years (S.D. = 10.6), and 142 of the patients were men. Cardiac rehabilitation attendance and quality of life were assessed via a postal questionnaire 6 months later. RESULTS: In contrast to previous work reported in this area, illness perceptions were not significantly associated with attendance at cardiac rehabilitation. Illness perceptions measured within 24 h of an acute MI were predictive of quality of life 6 months later. CONCLUSION: Previous reports may have overestimated the extent to which illness perceptions predict attendance at cardiac rehabilitation. The relationship between illness perceptions and quality of life at 6 months suggests that interventions to alter illness perceptions, especially perceptions of consequences, may be useful in improving health-related quality of life (HRQoL) following an MI.     

Are medically unexplained symptoms and functional disorders predictive for the illness course? A two-year follow-up on patients' health and health care utilisation

Objective

To investigate whether the general practitioners' (GP) diagnosis of medically unexplained symptoms (MUS) and/or the diagnosis functional disorders (FD) can predict the patients' 2-year outcome in relation to physical and mental health and health care utilisation. Furthermore, to identify relevant clinical factors which may help the GP predict the patient's outcome.

Method

The study included 38 GPs and 1785 consecutive patients who presented a new health problem. The GPs completed a questionnaire on diagnosis for each patient. Patients completed the Common Mental Disorder Questionnaire (CMDQ) and the SF-36 questionnaire at baseline and after 24 months. A stratified sample of 701 patients was diagnosed with a psychiatric research interview. Data on health cost was obtained from national registers.

Results

A FD diagnosis following the research interview was associated with a decline in physical health (OR 3.27(95%CI 1.84-5.81)), but this was not the case with MUS diagnosed by the GP. MUS was associated with a poor outcome on mental health (OR 2.16 (95%CI 1.07-4.31)). More than 4 symptoms were associated with a poor outcome on physical health (OR 5.35 (95%CI 2.28-12.56)) and on mental health (OR 2.17(95%CI 1.02-4.59)). Neither FD nor MUS were associated with higher total health care use. However, FD (OR 2.31(95%CI 1.24-4.31)) and MUS (OR 1.98(95%CI 1.04-3.75)) was associated with increased cost in primary care.

Conclusion

Our current diagnoses of MUS show limitations in their prediction of the patients' illness course. Although, the ICD-10 diagnoses of functional disorders was not developed for the primary care setting, our results indicate that some of its elements would be useful to bring in when rethinking the diagnosis for MUS in primary care, elements that are easily obtainable for the GP in a normal consultation. Our results may contribute to the construction of a more useful diagnostic for these patients in primary care.     

Does alexithymia expose to mental disorder symptoms in late adolescence? A 4-year follow-up study

ObjectiveTo investigate the possible causal link between alexithymia and the emergence of anxiety and depression symptoms, as well as alcohol consumption in a sample of late adolescents.MethodThe nonclinical sample comprised late adolescents (n= 315), including both females (n= 256) and males (n= 59). The follow-up period was 4 years, and at baseline, the mean age of the subjects was 19 years (range 17−21 years). Alexithymia was measured with the 20-item Toronto Alexithymia Scale (TAS-20), depression symptoms with the short form of the Beck Depression Inventory (RBDI), anxiety with the State-Trait Anxiety Inventory (STAI) and alcohol consumption with the Alcohol Use Disorders Identification Test (AUDIT). The three TAS-20 subscales were assessed separately. Linear and cumulative logistic regression analyses were used for the evaluation of associations, and the analyses were adjusted with the corresponding baseline scores.ResultsThe TAS-20 total and subscale scores did not predict the RBDI or AUDIT scores at follow-up. However, the TAS-20 subscale “difficulty identifying feelings” was significantly associated with both STAI-State (P= .007) and STAI-Trait (P= .004) scores at follow-up.ConclusionsAlexithymic features may be individual predictors of later anxiety symptoms. The significant differences between the various dimensions of alexithymia should be considered in future studies.     

Do treatment and illness beliefs influence adherence to medication in patients with bipolar affective disorder? A preliminary cross-sectional study

Adherence to medication is essential for achieving good outcomes for patients with bipolar affective disorder. This study tested whether treatment and illness beliefs are important predictors of adherence to medication. Results indicate that beliefs are predictive, and may be a suitable target for modification in efforts to change behaviour.