Psychological treatment in primary care. This issue features four papers on psychological treatment in primary care. An editorial by Scott & Sensky (pp. 191–196) also discusses the methodology of such studies. Bower et al. (pp. 203–215) report a meta-analysis of controlled trials of counselling. There are benefits but they are modest. Consistent with this, Simpson et al. (pp. 229–239) report a controlled trial of psychodynamic counselling in chronic depression, with little benefit over routine GP treatment. Proudfoot et al. (pp. 217–227) report benefit from an innovative computerized interactive cognitive-behavioural program for depression and anxiety. Gabbay et al. (pp. 241–251) report on agreement on baseline problems between patient, GP and therapist from a controlled comparison of cognitive-behavioural therapy and non-directive counselling.

Randomized controlled trials (RCTs) of psychological interventions are still much less frequently published than drug trials. To have four papers (Bower et al. 2003; Proudfoot et al. 2003; Simpson et al. 2003; Gabbay et al. 2003) within a single issue of a leading psychiatry journal is indeed unusual. Together these four major papers provide evidence of the benefits and limitations of psychological interventions for common mental disorders.

The problems of understanding what causes chronic fatigue, its relationship to psychiatric disorders, and how best to treat it continue to baffle and bemuse clinicians and patients alike (Report to the CMO, 2002; Stanley et al. 2002). This edition of the journal carries four original papers that provide much needed knowledge in a subject riddled by polemic and prejudice (White, 2002).

Background. Counselling is frequently used in the management of common mental disorders (such as anxiety and depression) in primary care. However, there are concerns over the clinical effectiveness of counselling, both in comparison with usual general practitioner care, and with other treatments such as alternative psychological therapies and antidepressant treatment. This study used systematic review methodology to assess the current evidence-base.

Method. A systematic literature review located seven trials of relevance, comparing counselling with usual general practitioner care, cognitive-behaviour therapy and antidepressant medication. Data on internal and external validity were examined using a standardized quality rating scheme. Data concerning the impact of counselling on symptoms of anxiety and depression were pooled using meta-analytical procedures.

Results. The main analyses showed significantly greater clinical effectiveness of counselling compared with usual general practitioner care in the short-term (standardized mean difference −0·28, 95% CI −0·43 to −0·13, N=741, six trials) but not the long-term (standardized mean difference −0·07, 95% CI −0·26 to 0·12, N=447, four trials). Sensitivity analyses were undertaken to test the robustness of the results.

Conclusion. Counselling is associated with modest improvement in short-term outcome compared with usual general practitioner care, and thus may be a useful addition to mental health services in primary care.

Background. Cognitive-behavioural therapy (CBT) brings about significant clinical improvement in anxiety and depression, but therapists are in short supply. We report the first phase of a randomized controlled trial of an interactive multimedia program of cognitive-behavioural techniques, Beating the Blues™ (BtB), in the treatment of patients in general practice with anxiety, depression or mixed anxiety/depression.

Method. One hundred and sixty-seven adults suffering from anxiety and/or depression and not receiving any form of psychological treatment or counselling were randomly allocated to receive, with or without medication, BtB or treatment as usual (TAU). Measures were taken on five occasions: prior to treatment, 2 months later, and at 1, 3 and 6 months follow-up using the Beck Depression Inventory, Beck Anxiety Inventory and Work and Social Adjustment Scale.

Results. Patients who received BtB showed significantly greater improvement in depression and anxiety compared to TAU by the end of treatment (2 months) and to 6 months follow-up. Symptom reduction was paralleled by improvement in work and social adjustment. There were no interactions of BtB with concomitant pharmacotherapy or duration of illness, but evidence, on the Beck Anxiety Inventory only, of interaction with primary care practice. Importantly, there was no interaction between the effects of BtB and baseline severity of depression, from which we conclude that the effects of the computer program are independent of starting level of depression.

Conclusions. These results demonstrate that computerized interactive multimedia cognitive-behavioural techniques under minimal clinical supervision can bring about improvements in depression and anxiety, as well as in work and social adjustment, with and without pharmacotherapy and in patients with pre-treatment illness of durations greater or less than 6 months. Thus, our results indicate that wider dissemination of cognitive-behavioural techniques is possible for patients suffering from anxiety and/or 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[ges ]24) might have yielded more conclusive results.

Background. Good communication is a crucial clinical skill. Previous research demonstrated better clinical outcomes when practitioners and patients agree about the nature of patients' core presenting complaints. We investigated the nature of this agreement and its impact on outcome among depressed primary care patients.

Method. We compared presenting problem formulations completed by patients, GPs and therapists in a primary care randomized controlled trial of cognitive-behavioural therapy and non-directive counselling for depression. Participants compiled formulations from a list of 13 potential problems of self-completed questionnaires. Subjects scored at least 14 on the Beck Depression Inventory (BDI) at baseline. Outcome measure for this study included BDI at 4 and 12 months, failure to attend for therapy when referred, dropout from therapy and patient satisfaction.

Results. Among 464 trial patients, 395 received therapy. Patient baseline problem formulations included significantly more items than GPs, who identified significantly more items than therapists. Agreement levels varied according to a range of patient and professional variables. While patients in complete agreement with their therapists about their main problem after assessment had lower average BDI scores at 12 months (9·7 v. 12·8, P=0·03); we found no other significant associations between the extent of agreement and clinical outcome. There were significant (but relatively weak) associations between agreement and aspects of patient satisfaction.

Conclusion. Our results suggest that detailed mutual understanding of the presenting complaints may be less important than agreement that the core problem is psychological, and that referral for psychological therapy is appropriate.

Background. Chronic fatigue and chronic fatigue syndrome are most often encountered in primary care settings. Given the disabling nature of chronic fatigue it may have a substantial impact on service use and costs as well as on employment. This study estimates this impact.

Method. Patients presenting to general practitioners with unexplained chronic fatigue were recruited to the study. Service use over a 3 month period was measured and lost employment recorded. These data were used to estimate economic costs. Patients with chronic fatigue syndrome were compared to patients with only chronic fatigue using a multiple regression model with sample differences controlled.

Results. The mean total cost of services and lost employment across the sample was £1906 for the 3-month period with formal services accounting for 9·3% of this figure. Service use was higher for patients with chronic fatigue syndrome compared to those with chronic fatigue alone. Total 3-month costs were on average higher for chronic fatigue syndrome (£3515 v. £1176) but when sample differences were taken account of the mean difference was reduced to £1406 (P=0·086). Over 90% of the cost was accounted for by care provided by friends and family members and by lost employment. Patients with dependants had significantly higher costs than those with none and costs were also significantly higher for greater levels of functional impairment.

Conclusion. Chronic fatigue imposes substantial economic costs on society, mainly in the form of informal care and lost employment. Treatments need to be developed which recognize these impacts.

Background. Fatigue is a complex symptom associated with many physiological, psychological and pathological processes. Its correlates and typology remain inadequately understood.

Method. These data were from two large, longitudinal twin studies. Trained interviewers enquired as to the presence of a [ges ]5 day period in the previous year of fatigue or tiredness that interfered with daily activities. A range of potential correlates was assessed in a structured interview: demography; health beliefs; the presence of nine physical disorders; mood, anxiety and addictive disorders; neuroticism and extraversion; recollections of parental rearing; and nine stressful life events. Statistical analyses included logistic regression, CART, MARS, latent class analysis and univariate twin modelling.

Results. Data were available for interfering fatigue (IF) on 7740 individual twins (prevalence 9·9% in the previous year). IF was significantly associated with 42 of 52 correlates (most strongly with major depression, generalized anxiety disorder, reported major health problems and neuroticism). Multivariate analyses demonstrated that IF is a highly complex construct with different sets of correlates in its subtypes. There were two broad clusters of correlates of IF: (a) major depression, generalized anxiety disorder and neuroticism; and (b) beliefs of ill health coexisting with alcoholism and stressful life events. Twin analyses were consistent with aetiological heterogeneity – genetic effects may be particularly important in women and shared environmental effects in men.

Conclusions. IF is a complex and common human symptom that is highly heterogeneous. More precise understanding of the determinants of IF may lead to a fuller understanding of more extreme conditions like chronic fatigue syndrome.

Background. The objective of this study was to examine factors that predicted outcome in a chronically fatigued group of patients who were randomized to cognitive behaviour therapy or counselling in primary care.

Method. Illness perceptions, attributions, fatigue, disability and demographic variables were recorded at assessment and levels of fatigue and disability were measured at 6 months post randomization. Logistic regression was used to examine associations.

Results. Factors that predicted a poor outcome (four or more on the fatigue questionnaire) were: poor social adjustment at assessment; the patients self-report that they had never seen the GP for an emotional reason; a physical illness attribution; and, a long perceived future illness duration.

Conclusions. Patients who are more psychologically minded are more likely to improve with psychological treatments in primary care. General practitioners need to assess this before referring to an appropriate therapist.

Background. High rates of psychopathology and of personality problems have been reported in children and adolescents with chronic fatigue syndrome (CFS). It is not clear whether this is consequent on the experience of chronic physical ill health. We compare psychiatric adjustment in children with CFS and in children suffering from another chronic physical disorder (juvenile idiopathic arthritis or JIA).

Method. Our sample consisted of 28 children with CFS and 30 with JIA attending tertiary paediatric centres (age range, 11 to 18 years, mean 15, S.D. 2·3). In order to assess psychiatric status and functioning, we used the K-SADS psychiatric interviews, CGAS and Harter Self-Esteem Questionnaire with child subjects; behavioural questionnaires (CBCL) and child personality assessment interviews (PAS) with parent informants.

Results. Psychiatric disorders in the year prior to interview had been present significantly more commonly in the CFS group (72% v. 34% in JIA) and were more impairing to them (CGAS scores of 45 v. 77). Most common diagnoses in both groups were depressive and anxiety disorders. Personality problems were also significantly more frequent in CFS subjects (48% disorder and 26% difficulty v. 11% and 11% in JIA). There were few differences between the two groups in self-esteem.

Conclusions. Psychopathology and personality problems are common in children and adolescents with severe forms of CFS and cannot be explained strictly through the experience of chronic physical illness.

Background. Social disadvantage and lack of social support have been identified as important risk factors for the onset and continuance of episodes of common mental illness. This study aimed to identify the social precursors to episodes of and recovery from common mental illness in a large, general population sample over eight yearly intervals.

Method. The analytical samples were drawn from those aged [ges ]16 in the British Household Panel Survey from 1991 to 1998. The samples were: (1) onset – over 42 000 paired years from 10 204 persons; (2) recovery – over 10 000 paired years from 4878 persons; and (3) 1812 spells with observed onset and recovery. Markov and discrete-time complementary log–log models were used. Common mental illness was measured using the 12-item General Health Questionnaire.

Results. Sex, age, changes in marital and employment status, physical health, family care and social support were all associated with differential rates of onset and recovery. Severity of disorder was associated with less likelihood of recovery and longer time to recovery.

Conclusions. The study confirms many previous findings concerning social factors associated with onset and recovery. Low social support acted as expected by increasing chances of onset and decreasing chances of recovery. Other social factors such as separation or divorce, becoming and remaining unemployed, health limiting daily activities, caring for a sick relative all decreased chances of recovery. The chances of observing a change in state (either onset or recovery) decreased with the number of prior observations in that state. Reduced rates of recovery with increasing degrees of severity of distress was expected, but not previously demonstrated.

Background. Current knowledge about associations between psychosocial factors and non-psychotic symptoms provide little information about their relationship to specific types of neurotic symptoms such as symptoms of fatigue, worry, phobic anxiety and obsessional symptoms.

Method. The British National Survey of Psychiatric Morbidity was based on a cross-sectional random sample of 10108 householders. Neurotic symptoms were established by lay interviewers using the revised fully structured Clinical Interview Schedule (CIS-R). Subjects were asked about perceived social support, the size of their close primary social network and sociodemographic attributes. To assess possible associations between specific types of neurotic symptoms and psychosocial risk factors multivariate Huber logistic models (a modified form of repeated measures design modelling) was used taking account of correlation between symptom types and sampling design including clustering.

Results. After controlling for sociodemographic factors the risk of having a high total CIS-R score ([ges ]12) was approximately doubled for both types of poor social functioning. Specific types of neurotic symptoms were associated both with a small primary group and with inadequate perceived social support. Depression, depressive ideas and panic symptoms had a higher prevalence in multivariate models. Poverty was associated with low support.

Conclusions. Associations with deficiencies in social support and self-reported neurotic symptoms are better explained by symptom type and in particular by depression than by the total number of symptoms. If confirmed by longitudinal study findings this knowledge could be used to inform the development of interventions to improve social support in order to reduce specific neurotic symptom types.

Background. Prior research on work-related factors in the aetiology of psychiatric disorders has been concentrated on job control, job demands and social support. To broaden the view to managerial procedures, we examined whether the extent to which employees are treated with equity in the workplace predicts their mental health. Organizational equity refers to decision-making procedures, which are consistently applied, open, correctable and include input from affected parties (procedural justice). It also refers to respectful and considerate treatment of individuals by supervisors (relational justice).

Method. A cohort of 1786 female hospital employees with no psychiatric disorder at baseline responded to a questionnaire on organizational equity. From the responses, both an individual score and a work unit mean score were assigned to each participant. The outcome was new reports of doctor-diagnosed psychiatric disorders during the 2-year follow-up. Odds ratios and 95% confidence intervals were corrected for clustering of the data.

Results. After adjustment for age and salary, odds ratio of new psychiatric disorders for self-reported low procedural justice was 1·9 (95% CI 1·1 to 3·2). Corresponding odds ratio for low procedural justice, as assessed with work unit mean scores, was 1·7 (95% CI 1·5 to 2·0). These associations remained statistically significant after additional adjustment for mental distress at baseline and job control, job demands and social support. Relational justice did not predict psychiatric disorders.

Conclusion. Research on organizational equity provides new information about potential work-related determinants of mental health. Low procedural justice seems to be an independent risk factor for psychiatric disorders in female employees.

Background. Life events (LE) have consistently been found to influence course and outcome of psychotic disorders. However, the mechanism through which they operate is not known. The present study investigated whether LE have their effect by impacting on the emotional sensitivity for daily hassles.

Method. Patients with clinically remitted psychotic illness (N=42) were studied with the Experience Sampling Method (a structured diary technique assessing current context and mood in daily life) to assess: (1) appraised subjective stress related to daily events and activities; and (2) emotional reactivity conceptualized as changes in both negative affect (NA) and positive affect (PA). LE were assessed with the Brown & Harris Life Event and Difficulties Schedule.

Results. Multilevel regression analyses showed that previous exposure to LE influenced the appraised stressfulness of neither daily events nor the activities in which the subjects were involved. However, a history of LE did modify the emotional reaction to daily life stress, both in models predicting NA and in models predicting PA.

Conclusions. By their cumulative effect on emotional reactivity to daily activities and events, LE may render individuals more vulnerable to the onset or persistence of psychotic experiences.

Background. Intellectual impairments are a recognized feature of tuberous sclerosis complex (TSC), but the frequency and degree of intellectual impairments has not been systematically studied in large epidemiological samples using standardized measures. As such, the form of the IQ distribution (uni- or bi-modal) has not been established and the relationship between IQ and other features (e.g. epilepsy history) is poorly delineated. To address these shortcomings, we assessed the intellectual abilities of a large epidemiological sample of individuals with TSC, drawn from the ‘Wessex’ area of SW England and compared them with the abilities of their unaffected siblings.

Method. Standardized tests were used to estimate the abilities of 108 (56 males, 52 females, median age=25, range=4–75) individuals with TSC and 29 unaffected siblings (14 males, 15 females, median age=18, range=6–55). Seizure history was obtained from informants and medical records.

Results. Estimated IQ was bi-modally distributed: 55·5% had an IQ in the normal range; 14% had mild to severe impairments; and 30·5% had profound disability (IQ<21). Forty-four per cent of the individuals with TSC had an IQ<70. In the subset of normally intelligent individuals with TSC, IQ was normally distributed with a mean of 93·6. This mean was significantly lower than the mean IQ of unaffected siblings (IQ=105·6). All individuals with learning disability had a history of seizures that usually commenced before 12 months of age and that often presented as infantile spasms. Multivariate analyses indicated that a history of seizures as well as a history of infantile spasms was predictive of the degree of intellectual impairment.

Conclusions. Intellectual abilities were bi-modally distributed in a representative sample of individuals with TSC. The likelihood of impairment was associated with a history of seizures, particularly infantile spasms. The genetic and brain basis of these findings requires further investigation.

Background. Objective data regarding adverse cognitive deficits associated with maintenance electroconvulsive therapy (M-ECT) are lacking. This study examined the cognitive state of depressive patients during M-ECT.

Method. A cross-sectional study was carried out in 11 depressive patients in remission, all with a DSM-IV diagnosis of major depressive disorder. The mean number of previous ECT sessions was 36·1, and the mean intersession interval was 52·7 days. A group of 11 patients who had not received ECT was selected for comparison and matched for diagnosis, sex, age and years of schooling. All subjects were assessed using a complete neuropsychological battery including memory, attention and frontal function tests.

Results. Groups did not present differences in long delay verbal recall. Encoding of new information and results on the frontal function tests were significantly lower in the M-ECT patients.

Conclusion. Depressed patients preserve long-term memory, but suffer short-term memory impairment and frontal function alteration during M-ECT. Further longitudinal studies are necessary to determine the influence of M-ECT on non-memory functions and different memory subtypes.

Background. We have developed the Major Depression Inventory (MDI), consisting of 10 items, covering the DSM-IV as well as the ICD-10 symptoms of depressive illness. We aimed to evaluate this as a scale measuring severity of depressive states with reference to both internal and external validity.

Method. Patients representing the score range from no depression to marked depression on the Hamilton Depression Scale (HAM-D) completed the MDI. Both classical and modern psychometric methods were applied for the evaluation of validity, including the Rasch analysis.

Results. In total, 91 patients were included. The results showed that the MDI had an adequate internal validity in being a unidimensional scale (the total score an appropriate or sufficient statistic). The external validity of the MDI was also confirmed as the total score of the MDI correlated significantly with the HAM-D (Pearson's coefficient 0·86, P[les ]0·01, Spearman 0·80, P[les ]0·01).

Conclusion. When used in a sample of patients with different states of depression the MDI has an adequate internal and external validity.

Background. Two new screening scales for psychological distress, the K6 and K10, have been developed but their relative efficiency has not been evaluated in comparison with existing scales.

Method. The Australian National Survey of Mental Health and Well-Being, a nationally representative household survey, administered the WHO Composite International Diagnostic Interview (CIDI) to assess 30-day DSM-IV disorders. The K6 and K10 were also administered along with the General Health Questionnaire (GHQ-12), the current de facto standard of mental health screening. Performance of the three screening scales in detecting CIDI/DSM-IV mood and anxiety disorders was assessed by calculating the areas under receiver operating characteristic curves (AUCs). Stratum-Specific Likelihood Ratios (SSLRs) were computed to help produce individual-level predicted probabilities of being a case from screening scale scores in other samples.

Results. The K10 was marginally better than the K6 in screening for CIDI/DSM-IV mood and anxiety disorders (K10 AUC: 0·90, 95%CI: 0·89–0·91 versus K6 AUC: 0·89, 95%CI: 0·88–0·90), while both were significantly better than the GHQ-12 (AUC: 0·80, 95%CI: 0·78–0·82). The SSLRs of the K10 and K6 were more informative in ruling in or out the target disorders than those of the GHQ-12 at both ends of the population spectrum. The K6 was more robust than the K10 to subsample variation.

Conclusions. While the K10 might outperform the K6 in screening for severe disorders, the K6 is preferred in screening for any DSM-IV mood or anxiety disorder because of its brevity and consistency across subsamples. Precision of individual-level prediction is greatly improved by using polychotomous rather than dichotomous classification.

Background. In both psychiatrically ill and psychiatrically healthy adults, the connection between health and individuals' height and weight has long been examined. Specifically, research on the idea that individuals with certain body types were prone to particular psychiatric diseases has been explored sporadically for centuries. The hypothesis that psychiatrically ill individuals were shorter and weighed less than psychiatrically healthy counterparts would correspond with the neurodevelopmental model of psychiatric disease.

Method. To evaluate possible links between psychiatric illness and physique, the height, weight and BMI of 7514 patients and 85 940 controls were compared. All subjects were part of the National Collaborative Study of Early Psychosis and Suicide (NCSEPS). Patients were US military active duty personnel hospitalized for either bipolar disorder, major depressive disorder, or schizophrenia and controls were psychiatrically-healthy US military active duty personnel matched for date of entry into the service.

Results. No consistent differences in height, weight or BMI were found between patients and controls, or between patient groups. Some weak ANOVA differences were found between age at the time of entering active duty and weight, as well as BMI, but not height.

Conclusions. Unlike most previous studies that have looked at the links between height and psychiatric illness, this study of the NCSEPS cohort found that, at entry into the US Armed Forces, there were no consistent decreases in height for patients with bipolar disorder, major depressive disorder or schizophrenia compared with a large control group. Furthermore, there were no consistent differences for weight or BMI.