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Attempted suicide in Oxford and Utrecht.
BACKGROUND: Attempted suicide rates are much higher in the UK than in the Netherlands. We have compared the characteristics of suicide attempters referred to general hospitals in Oxford and Utrecht. METHOD: We compared the characteristics of referrals for attempted suicide to a general hospital in Oxford and one in Utrecht, for the years 1988 and 1989. RESULTS: Most of the attempters in Oxford were young whereas attempters in Utrecht were older; this age difference was particularly marked in females. Utrecht attempters appeared more often to have socio-economic problems and to suffer from psychiatric and personality disorders (except substance abuse), even when account was taken of the age differences of the two populations. CONCLUSIONS: There is some evidence for different thresholds for attempted suicide in the UK and the Netherlands, although other social explanations for the difference in attempted suicide rates are feasible and require further study.
Do psychosocial factors influence outcome in severely depressed female psychiatric in-patients?
Fifty-nine women admitted to hospital because of severe depression were studied prospectively during hospital admission and nine months following hospital discharge in order to identify psychosocial and illness factors associated with prognosis. Outcome was measured in terms of both depression scores and recovery at the time of follow-up. In keeping with the findings of other studies, the outcome was often poor, with only 54% having recovered nine months after discharge, poorer outcome being associated with more negative self-esteem measured when the women were depressed and with suicidal ideas. The findings indicate that in severely depressed women likely to be admitted to hospital, psychosocial factors may have less relevance to outcome, at least in the short term, than in less severely depressed patients studied in community or out-patient samples.
Discrimination between psychogenic and organic erectile dysfunction.
The aim of this study was to develop a screening test based on the Leiden Impotence Questionnaire (LIQ) in order to assist in the difficult process of differentiating between psychogenic and organic erectile dysfunction (ED). The main sample consisted of 176 patients with ED, which was classified according to the results of the urological and psychiatric assessment as either organic, in 109 (62%) patients, or psychogenic, in 67 (38%) patients. A logistic regression model including six general items from the LIQ correctly identified psychogenic ED in 62% of the cases, and organic ED in 86%, with an overall correct classification rate of 76%. Adding information regarding sexual intercourse and the relationship in patients who had a partner and were having sexual intercourse the correct classification rates were: psychogenic 77%, organic 94%, and overall 87%. Discrimination between psychogenic and organic ED is improved when more information concerning sexual activity can be assessed.
Deliberate self-poisoning and self-injury in adolescents. A study of characteristics and trends in Oxford, 1976-89.
In Oxford during the late 1970s and early 1980s a decline in rates of deliberate self-poisoning and self-injury in older female teenagers was followed by a steady increase between 1986 and 1989. Rates for male adolescents and young female adolescents remained relatively stable throughout 1976-89. Applying the Oxford rates to England and Wales suggest a total of 18,000-19,000 hospital-referred cases per year. While self-poisoning with minor tranquillisers and sedatives has declined, there has been a marked increase in paracetamol self-poisoning, such that by 1988-89 it was involved in 48.3% of overdoses. Relationship difficulties were the most frequent problems faced by these adolescents, especially the females, with unemployment and alcohol and drug problems also being common, especially in males, but psychiatric disorders relatively rare. Substantial proportions of the adolescents, especially the males, were not living with either relatives or friends, and had a history of violence or a criminal record. The annual rate of repetition of attempts, which was 8.9% overall, was higher in adolescents not admitted to the general hospital, and in females not referred to the hospital psychiatric service. Adolescent attempted suicide clearly continues to be a major health problem for which both effective preventive and therapeutic strategies are badly needed.
Psychiatric problems among medical admissions.
The prevalence, nature, associations and outcome of psychiatric morbidity among four hundred and fifty severe general medical admissions are described. Affective disorder was diagnosed in 13 percent of men and 17 percent of women. It was associated with a history of previous psychiatric disorder and current social problems. Persistent affective disorder after discharge was associated with continuing medical and social problems. Alcohol problems were common in men, especially in those with social problems, and often went unrecognized by medical staff. Cognitive impairment was confined to the elderly and was associated with longer hospital stay and high mortality. Patients with emotional and cognitive disorder make considerable demands on medical, social and psychiatric services during and following admission. The implications for improved recognition and management of psychiatric morbidity in general medical patients are discussed.
Low sexual desire: sex therapy results and prognostic factors.
In a prospective study of 60 couples who entered sex therapy because of the female partners' low sexual desire, 38 (63.3%) completed treatment and 34 (56.7%) had a positive outcome. The principal predictor of completion of treatment was the male partners' apparent motivation at the outset. Poorer outcome was associated with younger age of the couple (especially the male partner) and a shorter duration of the sexual problem. Surprisingly, few aspects of the couples' general relationships prior to treatment were related to outcome, except for poorer outcome being associated with a history of previous separations. The apparent lack of significant contribution of general relationship factors and psychopathology to outcome probably reflects the stringency of the initial selection process. Eventual outcome was also related to couples' progress by the third treatment session. The modest outcome of treatment for low sexual desire in this and other studies emphasises the need for further understanding of factors which contribute to this problem and for the development of novel treatment strategies.
Significance of psychiatric symptoms in general medical patients with mood disorders.
Little difference was found between the psychiatric symptoms of medical patients and general-population subjects with affective disorder, both groups having been assessed with the same procedure (Present State Examination). Discrimination between medical patients with and without affective disorder was best achieved when patients with depressive and anxiety disorders were considered separately. Depressed mood, morning depression, and hopelessness were the key symptoms in the depressives, and nervous tension, free-floating anxiety, panic attacks, and specific phobias in the patients with anxiety disorders. Symptom profile did not distinguish patients with persistent affective disorders from those whose disorders had resolved at a 4-month follow-up.
The relationship between intellectual impairment and mood disorder in the first year after stroke.
In a community-based study of patients with a first-ever stroke, intellectual impairment (as defined by scores on a common screening test for dementia, the Mini-Mental State Examination) was found in 26% at 1 month post-stroke, and in 21% at 6 and 12 month follow-up. Low scores on the screening test were associated with greater age, physical disability before the stroke, larger stroke lesion volumes as measured on CT scan, and non-stroke changes such as atrophy and white matter low attenuation on the CT scan. There was a negative correlation between scores on the Mini-Mental State Examination and symptom levels on two measures of mood disorder. However, there was no evidence of a specific relationship between major depression and low scores on the Mini-Mental State. We examined various aspects of the relationship between mood symptoms and low scores on the Mini-Mental State, but found no evidence to support the suggestion that this relationship represented an example of depressive pseudodementia. We discuss the significance of our findings for clinical psychiatry and neuropsychology.
Life events and difficulties preceding stroke.
Life events and difficulties were recorded for the year before stroke, using a standardised semi-structured interview, in 113 surviving patients seen after their first ever in a lifetime stroke. An age and sex-matched control group (n = 109) was also interviewed about the preceding year. The stroke patients reported fewer non-threatening events and events with only a short-term threat, while difficulties were reported with equal frequency by the two groups. However, events which were severely threatening in the long-term were significantly more common in the stroke patients (in the 52 weeks before stroke 26% versus 13%, odds ratio 2.3, 95% confidence interval 1.1-4.9). The increased rate was apparent throughout the year and not just in the weeks immediately before stroke onset. The number of stroke patients experiencing severe events in the follow up year fell to the level found in the control group. Recognised risk factors for stroke were found equally in those patients with and without severe events before onset, except that hypertension was rather less common in the patients who had experienced a severe event. It therefore appears that severe life events may be one of the determinants of stroke onset.
What happens to medical patients with psychiatric disorder?
Medical, psychiatric and social outcome were examined in medical in-patients previously identified as suffering from psychiatric disorder. One third of patients with an affective (emotional) disorder on admission were still psychiatrically ill four months after discharge. Persistent disorder was associated with continuing physical illness. During the year following admission those with affective disorder on admission continued to make greater demands on medical, social and psychiatric services than matched controls and had double the mortality rate (not significant). Patients with organic mental states on admission had a high mortality and morbidity, and made considerable continuing use of general hospital social and psychiatric services. Improved recognition of psychiatric disorder during hospital admission could result in better overall care of medical patients' psychiatric and social difficulties and more effective use of medical resources.
Erectile dysfunction and premature ejaculation.
In parallel with the increased recognition of organic causes of erectile dysfunction, several new physical methods of treatment have been developed for this problem. These include intracavernosal injections of vasodilators, penile prostheses, vascular surgery, vacuum condoms, and medication. However, psychological treatment approaches are still of considerable importance in the treatment of both erectile dysfunction and premature ejaculation.
Psychiatric disorder in the general hospital.
There have been many reports of psychiatric disorder in medical populations, but few have used standard methods on representative patient groups. Even so, there is consistent evidence for considerable psychiatric morbidity in in-patient, out-patient and casualty department populations, much of which is unrecognised by hospital doctors. We require a better classification of psychiatric disorder in the general hospital, improved research measures, and more evidence about the nature and course of the many different types of problem so that we can provide precise advice for their management of routine clinical practice.
Sexual adjustment of men who have had strokes.
Fifty men who had suffered moderate to severe strokes were interviewed approximately six months later and asked about their sexual adjustment. Interest in sex had returned in most cases, although the level of interest was reduced in some. Nearly all the men had regained their erectile capacity, usually after a delay of approximately seven weeks following the stroke. Of those sexually active with their partner before their strokes, over half had resumed sexual intercourse by the time of the interview. Most of these men had encountered difficulties because of the physical consequences of their strokes, but two-thirds had tried new sexual positions to compensate for this. Whether or not a couple resumed sexual activity after the man's stroke was largely predictable on the basis of the frequency of their previous sexual activity, rather than the man's age or the severity of physical disability. For patients who are sexually active before suffering strokes, subsequent rehabilitation should include brief counselling on sexual readjustment for both the patients and their partners.
Motivational aspects of deliberate self-poisoning in adolescents.
A systematic study of 50 adolescent self-poisoners aged from 13 to 18 demonstrated considerable discrepancies between the reasons chosen by the subjects to explain the overdoses and those chosen by clinical assessors. Most adolescents indicated that they had been feeling lonely or unwanted, or angry with someone, and had taken the overdose to alleviate or demonstrate this distress. A third said they had wanted to die. In contrast, clinical assessors tended to attribute the overdose to punitive or manipulative reasons and suggested that only seven out of the 50 had wished to die. The adolescents rarely indicated that they had taken the overdose to get help; this may explain the resistance that may be shown to psychiatric intervention, that casts doubt on the possible effectiveness of preventive agencies. Modification of attitudes to both self-poisoning and early help-seeking may be a more effective means of prevention.
The attitudes of psychiatrists to deliberate self-poisoning: comparison with physicians and nurses.
The attitudes of junior psychiatrists to deliberate self-poisoning were assessed on the basis of their answers to a series of questions concerning four case vignettes. They spontaneously indicated goals for the behaviour in only a minority of cases. Emphasis should be placed on identifying instrumental aspects of overdoses during training in the assessment of self-poisoning patients. The psychiatrists attributed similar reasons for the cases as did physicians and nurses who were previously investigated using the same method. However, compared with the physicians, the psychiatrists showed more sympathetic attitude to the patients and their behaviour, and a greater willingness to help them. The psychiatrists and nurses were similar in this respect. The findings are discussed in the light of recent innovations in the management of self-poisoning patients in general hospitals.