Neuroticism in relation to recovery and persisting pain after laparoscopic cholecystectomy

BACKGROUND

Persisting pain is seen in 20%-30% of patients after cholecystectomy for symptomatic gallbladder stones. The only preoperative factor that seems predictive is psychic vulnerability or neuroticism. Findings with regard to the influence of psychologic factors on recovery are contradictory, too. The aim of the present study was to examine a possible relationship between neuroticism and recovery and the outcome of operation.

METHODS

Ninety-four patients who had had a laparoscopic cholecystectomy performed were tested psychologically with a Danish psychic vulnerability scale and with the Eysenck Neuroticism Scale before and 1 year after operation. The course of recovery was registered 1 month after operation, and outcome with regard to persisting pain 1 year postoperatively.

RESULTS

No correlations were found between neuroticism scores and postoperative hospital stay or time to regain work/normal activities (P > 0.05). Persisting pain was found in 18% of the patients 1 year after operation. Although the patients with persisting pain had higher neuroticism scores preoperatively, the difference from the patients with successful outcome of the operation first became statistically significant 1 year postoperatively (P < 0.01-0.05).

CONCLUSIONS

The results do not indicate that neuroticism influences the short recovery process after laparoscopic cholecystectomy. With regard to persisting pain, the higher neuroticism scores in these patients 1 year after the operation could be the consequence of the pain rather than aetiologic factors.

Morning fluoxetine plus evening mianserin versus morning fluoxetine plus evening placebo in the acute treatment of major depression

In a randomized clinical study the combination of fluoxetine 20 mg daily and mianserin 30 mg daily was compared to fluoxetine 20 mg daily and a mianserin placebo. In total, 34 patients with major depression were randomized, of whom 16 received fluoxetine plus mianserin; 18 patients received fluoxetine plus placebo. Of these patients, 69% completed the planned trial of six weeks in the fluoxetine plus mianserin group while 61% completed in the fluoxetine plus placebo group. In the efficacy analysis (excluding dropouts from the first two weeks of treatment) the combination of fluoxetine and mianserin was superior to fluoxetine and placebo both in observer ratings of depression and in quality of life ratings. However, in the intention-to-treat analysis this difference was not statistically significant. No major side effects were reported. After four weeks of treatment headache was most often seen in the fluoxetine and mianserin combination, while sweating was most often seen in the fluoxetine plus placebo group. No pharmacokinetic interaction in terms of fluoxetine plasma levels was found in the mianserin-treated patients.

The Major Depression Rating Scale (MDS). Inter-rater reliability and validity across different settings in randomized moclobemide trials. Danish University Antidepressant Group

The Major Depression Rating Scale (MDS) has been derived from the Hamilton Depression Scale and the Melancholia Scale. The MDS contains the nine DSM-IV items for major depression which all have anchoring scores from 0 to 4; hence, the theoretical score range is up to 36. The Major Depression Rating Scale has in this study been psychometrically analysed in randomized moclobemide trials. The results showed that the MDS had higher internal validity than the Hamilton Depression Scale. Thus, the homogeneity of the items was higher; factor analysis identified only one general depression factor (after 4 weeks of treatment explaining more than 50% of the variance). The inter-rater reliability of the two scales was of the same high level. The ability to measure changes (external validity) was tested in randomized clinical trials with moclobemide versus tricyclics (clomipramine and notriptyline) performed in Denmark in the psychiatric setting as well as in the general practice. The results showed that in the psychiatric setting tricyclics were superior to moclobemide with effect sizes ranging between 0.43 and 0.53. The highest effect size was obtained with the Melancholia Scale and the Major Depression Rating Scale, while the Hamilton Depression Scale was below 0.50. In the general practice setting no difference was found between moclobemide and clomipramine. In conclusion, the Major Depression Rating Scale has been found to have a more homogeneous factor structure than the Hamilton Depression Scale, but still with the same level of reliability and external validity. However, studies are needed to standardize the scale, especially in the general practice setting.

Relapse prevention by means of paroxetine in ECT-treated patients with major depression: a comparison with imipramine and placebo in medium-term continuation therapy

In-patients with severe major depression were treated in the acute phase with electroconvulsive therapy (ECT) in combination with antidepressants. The drug treatment consisted of two randomized trials which were both extended into the post-ECT continuation phase. Patients with electrocardiological impairment were randomized to either 30 mg paroxetine daily or placebo under blind conditions. Patients without electrocardiological impairment were randomized to either 30 mg paroxetine daily or 150 mg imipramine daily. There was a high level of agreement between the Hamilton Depression Scale and the Melancholia Scale, demonstrating that the patients treated with ECT plus imipramine in the acute phase showed greater symptom reduction than those treated with ECT plus paroxetine. However, in the post-ECT phase paroxetine was superior to both imipramine and placebo in preventing relapse. Thus in the post-ECT phase 65% of the placebo-treated patients relapsed, compared to 30% of the imipramine-treated patients and 10% of the paroxetine-treated patients. The psychometric analysis of the Melancholia Scale in the continuation or post-ECT phase showed that relapsing patients displayed a pattern with lack of interests, impaired concentration, depressed mood and anxiety among the less severe symptoms (first-compartment symptoms). In other words, these symptoms represent the gate to full-blown depression (second-compartment symptoms). Serotonin-selective antidepressants such as paroxetine appear to be more effective in controlling the first-compartment symptoms.

Screening and treating depressed patients. A comparison of two controlled citalopram trials across treatment settings: hospitalized patients vs. patients treated by their family doctors. Danish University Antidepressant Group

This study is a comparison across treatment settings of two previously published trials, namely the Danish University Antidepressant Group (DUAG) study on citalopram vs. clomipramine in hospitalized patients with major depression, and the Nordic citalopram vs. imipramine study of depressed patients treated by their family doctors. The Hamilton Depression Scale (HAM-D) had the same level of inter-rater reliability and construct validity in the two settings. Using a HAM-D score of 7 or less as the criterion for full two remission, clomipramine was superior to imipramine and citalopram. Using a reduction of the baseline HAM-D score by 50% or more as a response criterion, there were no differences between the three antidepressants after 5 or 6 weeks of treatment. Citalopram showed superior tolerability to the tricyclic antidepressants.

Quality of life in anxiety and social phobia

Most studies on anxiety including social phobia have measured social adjustment behavior rather than quality of life (i.e. the subjective perception of the patient of his or her illness in relation to different domains). These social adjustment studies have found panic disorders to be more disabling than social phobia. However, quality of life was measured in terms of subjective well-being or satisfaction, and the Zürich study showed that patients with social phobia had less well-being in domains of friends, partner and childhood memories than patients with other anxiety or mood disorders. It is concluded that shyness has a great impact on quality of life.

The WHO (Ten) Well-Being Index: validation in diabetes

BACKGROUND

In a European trial in 8 countries, the subjective well-being of patients on alternative forms of treatment for insulin-dependent diabetes was compared using the 28-item WHO Well-Being Questionnaire, covering four dimensions of depression, anxiety, energy and positive well-being. The objective of the analysis reported here has been to identify the items of the WHO questionnaire which belong to an overall index of negative and positive well-being.

METHODS

Adult patients at 10 study centres in 8 countries who had been on insulin for at least 2 years were invited to participate in a randomised, cross-over trial to compare insulin pump treatment with injection therapy. At each phase, patients completed questions on well-being and general health. Internal validity of the well-being index was evaluated by Cronbach's alpha and Loevinger's and Mokken's homogeneity coefficients, as well as factor analysis. External validity was evaluated by comparisons with results of the general assessment questions and by the ability to discriminate between the alternative forms of treatment.

RESULTS

358 patients had sufficient data for analysis. Ten items were found to constitute a valid index of well-being with respect to internal and external validity. Coefficients of homogeneity were acceptable and there was evidence for both concurrent and discriminant validity.

CONCLUSIONS

The WHO (Ten) well-being index includes negative and positive aspects of well-being in a single uni-dimensional scale. Its advantage lies in its ability to show overall change along the continuum of well-being, thus facilitating comparisons between patient groups and treatments. It is not specific to diabetes, and therefore may be useful as a disease-independent index of well-being in a broad range of health care studies.

[Symptoms of depression in cancer patients undergoing chemotherapy]

Symptoms of depression and anxiety were measured in a prospective follow-up study of 36 cancer patients before and during chemotherapy by means of the Hamilton rating scales and the Melancholia Scale. These scales proved useful in the examined population. Moderate or severe depression was seen in almost half of the patients before chemotherapy, but this figure decreased during follow-up. The symptomatology resembled that of primary depression, and the brief rating scales for depression seemed suitable for screening purpose. Problems in identifying morbid states of anxiety and depression are discussed.

Social aspects of treatment of depression

Epidemiological studies of depression have shown a consistent, clinical syndrome across different societies, most of the symptoms being included in DSM-III-R. It is an illness associated with considerable impairment of social function, and in DSM-IV social or occupational dysfunction is included as a criterion for diagnosis. There is also an increased suicide risk which has to be taken into account when selecting treatment. Most depression is treated in general practice, where treatment has tended to be of short duration. The usefulness of tricyclic antidepressants in limited by their toxicity in overdose and their unwanted side effects, which lead to the overuse of health care facilities, reduce compliance, and have social and quality of life consequences particularly in long-term treatment. On these measures the selective serotonin reuptake inhibitors offer a preferred choice of treatment in view of their improved safety and tolerability profile.

Quality-of-Life measurements for patients taking which drugs? The clinical PCASEE perspective

Of the many publications on quality of life in medicine over the last 2 decades, only a minor fraction have been devoted to drug trials. The most frequently investigated are classes of drugs within cancer disorders, hypertension and depressive illness. Health-related quality-of-life (QOL) measurements are typically applied in chronic or subchronic disorders where the balance between effectiveness (disease-modifying drug effects) and safety (adverse drug reactions) are assessed by patients in terms of subjective well-being. In this context, quality of life is an attempt to help the doctor to listen to his or her patient. The components of QOL measurements are to be found within the PCASEE model where: P = physical indicators; C = cognitive indicators; A = affective indicators; S = social indicators; E = economic-social stressors or negative life events; and E = ego function or personality problems. Most variance in QOL measurements arises through operating in the cognitive (e.g. lack of control, concentration difficulties) or affective (e.g. depressed mood or anxiety) components. The most specific component is, of course, adverse drug reactions, which are typically gastrointestinal symptoms in cancer therapies, and circulatory symptoms and sexual function with antihypertensive drugs. However, the affective and cognitive components also have different weights within subclasses of drugs, such as antihypertensive agents. Thus, angiotensin converting enzyme inhibitors act on the affective component (depression and anxiety) and calcium channel blockers on the cognitive component (neurasthenia). In general, patients with cancer or hypertension give more reliable assessments of their cognitive and affective symptoms than their doctors do, while patients with primary depression are less reliable than their doctors or relatives in measuring changes in the affective components of their illness when they are ill. Health-related QOL measurements have not only an impact on the doctor-patient relationship but also involve a holistic approach to drug treatment, by checking all the PCASEE components.

Beyond the Hamilton depression scores in long-term treatment of manic-melancholic patients: prediction of recurrence of depression by quality of life measurements

This study should be considered as a pilot study to investigate the applicability and validity of quality of life scales in manic-melancholic patients in long-term, prophylactic treatment. The quality of life instruments included the SmithKline Beecham Quality of Life (SBQOL) scale, the PCASEE questionnaire (a modified paper-and-pencil version of the computerized SBQOL), the Psychological General Well-Being (PGWB) scale, and the Medical Outcomes Study (SF-36) scale. The patients (n = 23) fulfilled the DSM-IV criteria of bipolar or recurrent depressive disorders. They were investigated in a symptom-free period (HAM-D < 14) and again 4 weeks later. The results showed that the quality of life scales had an adequate applicability and internal validity. Furthermore, at first visit a factor analysis identified two factors of which the quality of life scales loaded on the first factor (positive well-being) and the Hamilton scales loaded on the second factor (negative well-being). At the second visit, only one, general, factor emerged, because some of the patients had relapsed. Those patients with a relapse had low quality of life scores at the first visit indicating that the quality of life scales can predict recurrence of depression.

The borderline syndromes of depression, mania and schizophrenia: the coaxial or temperamental approach

When analyzing the diagnostic position of "neurosis", Akiskal found it clinically meaningless because it lacks sufficient phenomenological characterization. In contrast, Tyrer found it meaningful because it explains the heterogeneity of neurotic symptoms. The diagnostic position of "borderline" has been treated analogically by Akiskal and Tyrer. Thus, Tyrer uses the term borderline in a very broad and general sense, while Akiskal again has found it without sufficient phenomenological characterization. Hence, the DSM-III concept of borderline personality disorder includes the temperament borders of affective disorders (melancholic, choleric and sanguine). A closer look at the Tyrer concept of neurosis places it within the melancholic temperament. The choleric temperament covers cyclothymia and the sanguine temperament the subclinical manifestations of mania. The term borderline personality disorders should, then, be restricted to cover the phlegmatic temperament or mild degrees of the schizophrenic spectrum disorders, which is in accordance with ICD-10.

Post-stroke depression: combined treatment with imipramine or desipramine and mianserin. A controlled clinical study

In a 6-week study the efficacy of combined treatment of imipramine plus mianserin was compared to combined treatment of desipramine plus mianserin in patients with post-stroke depression. Patients were required to have a minimum baseline total score of 15 on the 17-item Hamilton Depression Scale (HAMD). The Melancholia Scale (MES) was also used to measure severity of depressive states to show that somatic symptoms had little influence on the evaluation of depression. Out of 120 stroke patients screened, 20 patients fulfilled the inclusion criteria. The doses of the drugs were flexible, using side-effects as a guide during treatment. Both intention to treat analysis and efficacy data (excluding patients who had dropped out during the first 2 weeks of treatment) showed that imipramine (mean dose 75 mg daily) plus mianserin (mean dose 25 mg daily) was superior to desipramine (mean dose 66 mg daily) plus mianserin (27 mg daily). The MES was found to be more sensitive than the HAMD for measuring change in depressive states during treatment. The assessment of side-effects using the UKU scale showed good tolerance in general. The only difference between the two treatment groups was seen in micturition disturbances, where the imipramine treated patients had most complaints after 14 days of treatment, but the symptoms disappeared despite continuous treatment.

Depressive symptoms in cancer patients undergoing chemotherapy: a psychometric analysis

Depressive psychopathology was measured in a prospective follow-up study of 36 cancer patients. The psychometric properties of the Hamilton rating scales for depression and anxiety and the Melancholia Scale were examined. The scales proved useful, indicating that the symptomatic structure of depression in cancer patients is rather identical to that seen in primary depression. Depressive states were found in about 40% of patients before the start of chemotherapy. The frequency of intermediate and high scores on the depression scales showed a low to moderate decrease after 6 months. Aspects of depression in the medically ill are discussed, and screening routines suggested.

The validity of Eysenck's neuroticism dimension within the Minnesota Multiphasic Personality Inventory in patients with duodenal ulcer. The Hvidovre Ulcer Project Group

A psychometric analysis on patients with duodenal ulcer using latent structure coefficients (Loevinger and Mokken) showed that the MMPI subscales of depression, psychasthenia, hypochondriasis, hysteria, schizophrenia and social introversion all could be considered as indicators of Eysenck's dimension of neuroticism. Both a MMPI neuroticism scale of 15 items (MMPI/N-15) and of 21 items (MMPI/N-21) were psychometrically valid, i.e. the total score was a sufficient statistic. Patients with duodenal ulcer who improved during treatment also had a significant decrease in their neuroticism scores, whereas patients who did not improve had unchanged neuroticism scores. In other words, neuroticism is secondary to the clinical symptoms of duodenal ulcer (a psychological adjustment to illness) and not an etiological factor.

Acute therapy of depression

The acute therapy (the initial 8 weeks of treatment) of depression (including the whole spectrum of "less than major," "major," and "more than major") has been reviewed comparing the old tricyclics with the new generations (especially mianserin, moclobemide, and the serotonin selective reuptake inhibitors (SSRIs), i.e., citalopram, fluoxetine, fluvoxamine, paroxetine, and sertraline). The Hamilton Rating Scale for Depression has been used to measure clinical efficacy. Statistically, the method of meta-analysis has been applied. The results showed that the SSRIs and moclobemide are equal to the tricyclics. Mianserin is inferior to tricyclics as well as to SSRIs. The antidepressive profile of the SSRIs is nonsedation but still with anxiolytic effects. The safety profile of the SSRIs is much more benign than that of the tricyclics.