Anxiety Disorders: Creed F

Jones MP, Crowell MD, Olden KW, Creed F. · Feinberg School of Medicine, Northwestern University, Chicago, IL 60611-2908, USA. · Psychosomatics. · Pubmed #17329601 links to  free full text

Abstract: Functional gastrointestinal disorders (FGID) are common conditions, with well-established diagnostic criteria. They are associated with impaired health-related quality of life and increased societal and healthcare costs. Their symptoms are probably related to altered 5-HT transmission and central processing of noxious visceral stimuli. Evaluation and treatment are best formulated using a biopsychosocial model that integrates gut function with psychosocial assessment. Psychological therapies may improve overall well-being and appear to help patients without significant psychiatric comorbidity. Antidepressants help comorbid anxiety and depressive disorders and have primary efficacy in improving the symptoms of FGID. Finally, there is a need for greater involvement of psychiatrists in both the evaluation and treatment of patients with FGID as well as the education and training of practitioners caring for these patients.

Levy RL, Olden KW, Naliboff BD, Bradley LA, Francisconi C, Drossman DA, Creed F. · University of Washington, Seattle, Washington 98105, USA. · Gastroenterology. · Pubmed #16678558 No free full text.

Abstract: This report reviews recent research on the psychosocial aspects of the functional gastrointestinal disorders (FGIDs). A review and evaluation of existing literature was conducted by a multidisciplinary committee of experts in this field. This report is a synopsis of a chapter published in the Rome III book. The committee reached consensus in finding considerable evidence supporting the association between psychological distress, childhood trauma and recent environmental stress, and several of the FGIDs but noted that this association is not specific to FGIDs. There is also considerable evidence that psychosocial variables are important determinants of the outcomes of global well-being, health-related quality of life, and health care seeking. In line with these descriptive findings, there is now increasing evidence that a number of psychological treatments and antidepressants are helpful in reducing symptoms and other consequences of the FGIDs in children and adults. The FGIDs are a result of complex interactions between biological, psychological, and social factors, and they can only be treated satisfactorily when all these factors are considered and addressed. Therefore, knowledge about the psychosocial aspects of FGIDs is fundamental and critical to the understanding, assessment, and treatment of these disorders. More extensive physician training is needed if these aspects of treatment are to be used effectively and widely in clinical practice.

Sheps DS, Creed F, Clouse RE. · University of Florida and the Malcom Randall VA Medical Center, P.O. Box 100181, Gainesville, FL 100181-0181, USA. · Psychosom Med. · Pubmed #15564350 links to  free full text

Abstract: OBJECTIVE: To describe factors influencing chest pain expression in patients with cardiac or noncardiac disease. METHODS: The authors conducted a case presentation and review of literature. RESULTS: Causes of chest pain are diverse. Psychologic factors influence chest pain expression commonly in patients with or without cardiac disease. CONCLUSIONS: Physicians and other therapists must be aware of psychologic influences on chest pain expression to provide optimal treatment to their patients.

Marshall M, Crowther R, Almaraz-Serrano A, Creed F, Sledge W, Kluiter H, Roberts C, Hill E, Wiersma D, Bond GR, Huxley P, Tyrer P. · University of Manchester, Guild Trust, Preston, UK. · Health Technol Assess. · Pubmed #11532238 links to  free full text

Abstract: ***ACUTE DAY HOSPITAL VERSUS ADMISSION FOR ACUTE PSYCHIATRIC DISORDERS*** BACKGROUND: Inpatient treatment is an expensive way of caring for people with acute psychiatric disorders. It has been proposed that many of those currently treated as inpatients could be cared for in acute psychiatric day hospitals. OBJECTIVE: The aim of this review was to assess the effectiveness and feasibility of day hospital versus inpatient care for people with acute psychiatric disorders. METHODS - STUDY SELECTION: Eligible studies were randomised controlled trials of day hospital versus inpatient care for people with acute psychiatric disorders. Studies were excluded if they were primarily concerned with elderly people, children, or patients with a diagnosis of organic brain disease or substance abuse. METHODS - DATA SOURCES: We searched the Cochrane Controlled Trials Register, MEDLINE, EMBASE, CINAHL, PsycLIT, and the reference lists of articles. Researchers were approached to identify unpublished studies. Trialists were asked to provide individual patient data. METHODS - DATA EXTRACTION: Data were extracted independently by two reviewers and cross-checked. METHODS - DATA SYNTHESIS: Relative risk (RR) and 95% confidence intervals (CIs) were calculated for dichotomous data. Weighted or standardised means were calculated for continuous data. Day hospital trials tend to present similar outcomes in slightly different formats, making it difficult to synthesise the data. Individual patient data were therefore sought so that outcomes could be re-analysed using a common format. RESULTS: Nine trials met the inclusion criteria (involving 1568 randomised patients and 2268 assessed for suitability of day hospital treatment). Individual patient data were obtained for four trials (involving 594 people). A sensitivity analysis of combined data suggested that day hospital treatment was feasible for at worst 23.2% (n = 2268; 95% CI, 21.2 to 25.2) and at best 37.5% (n = 1768; 95% CI, 35.2 to 39.8) of those currently admitted to inpatient care. Individual patient data from three trials showed no difference in the number of days in hospital (combining day hospital days and inpatient days) between day hospital patients and controls (n = 465; weighted mean difference (WMD) = -0.38 days/ month; 95% CI, -1.32 to 0.55). However, compared with controls, patients randomised to day hospital care spent significantly more days in day hospital care (n = 265; WMD = 2.34 days/month; 95% CI, 1.97 to 2.70) and significantly fewer days in inpatient care (n = 265; WMD = -2.75 days/month; 95% CI, -3.63 to -1.87). There was no difference between readmission rates for day hospital and control patients (n = 667; RR = 0.91; 95% CI, 0.72 to 1.15). Individual patient data from three trials showed a significant time-treatment interaction, indicating a more rapid improvement in mental state (n = 407; c2 = 9.66; p = 0.002), but not social functioning (n = 295; c2 = 0.006; p = 0.941) amongst day hospital patients. Four of five trials demonstrated that day hospital care was cheaper than inpatient care (with overall cost reductions ranging from 20.9% to 36.9%). CONCLUSIONS: Acute day hospitals are an attractive option in situations where demand for inpatient care is high and facilities exist that are suitable for conversion. They are a less attractive option when demand for inpatient care is low and where effective alternatives already exist. The interpretation of day hospital research would be enhanced if future trials made use of the common set of outcome measures used in this review. It is important to examine how acute day hospital care can be most effectively integrated into a modern community-based psychiatric service. ***VOCATIONAL REHABILITATION FOR PEOPLE WITH SEVERE MENTAL DISORDERS*** BACKGROUND: People who are disabled by severe mental disorders experience high rates of unemployment, but most want to work. Prevocational training (PVT) is the traditional approach to helping such people to return to work. PVT assumes that a period of preparation is required before those with a severe mental disorder can enter into competitive employment. Supported Employment (SEm) is a new approach that places clients in competitive employment without extended preparation. Both PVT and SEm are widely practised, but it is unclear which is the most effective. OBJECTIVES: The overall objective of this review was to assess the effectiveness of PVT and SEm relative to each other and to standard care (in hospital or the community) for people with severe mental disorders. In addition, the review examined the effectiveness of: (1) special types of PVT ("clubhouse" model) and SEm (individual placement and support model); and (2) modifications for enhancing PVT (e.g. payment or psychological interventions). METHODS - STUDY SELECTION: Eligible studies were randomised controlled trials (RCTs) examining the effectiveness of vocational rehabilitation approaches (PVT and SEm or modifications) for people of working age and suffering from a severe mental disorder. METHODS - DATA SOURCES: Relevant trials were identified from searches of the Cochrane Schizophrenia Group's specialised register, MEDLINE, EMBASE, CINAHL and PsycLIT, and the reference lists of all identified studies and review articles. Researchers who were active in the field were approached in order to identify unpublished studies. METHODS - DATA EXTRACTION: All data were extracted independently by two reviewers and cross-checked. Continuous data were excluded if they were collected by using an unpublished scale or were based on a subset of items from a scale. METHODS - DATA SYNTHESIS: For all comparisons, the primary outcome was the number of clients who were in competitive employment at various time points. Secondary outcomes were: other employment outcomes, clinical outcome and costs. The relative risk (RR) and number-needed-to-treat (NNT) were calculated for the relevant categorical outcomes. Continuous data were either presented as in the original trial reports or, where possible, combined across trials as a standardised mean difference score. RESULTS: Eighteen RCTs of reasonable quality were identified: PVT versus hospital controls, three RCTs, n = 172; PVT versus community controls, five RCTs, n = 1204; modified PVT, four RCTs, n = 423; SEm versus community controls, one RCT, n = 256; and SEm versus PVT, five RCTs, n = 491). The main finding was that, on the primary outcome (number in competitive employment), SEm was significantly more effective than PVT at all time points (e.g. at 12 months, SEm 34% employed, PVT 12% employed; RR of not being in competitive employment = 0.76, 95% confidence interval 0.69 to 0.84, NNT = 4.5). Clients in SEm also earned more and worked more hours per month than those in PVT. CONCLUSIONS: The main finding was that SEm was more effective than PVT for patients suffering from a severe mental disorder who wanted to work. There was no evidence that PVT was more effective than standard community care or hospital care. The implication of these findings is that people suffering from mental disorders who want to work should be offered the option of SEm. Commissioning agencies would be justified in encouraging vocational rehabilitation (VR) providers to develop more SEm schemes. From a research perspective, the cost-effectiveness of SEm should be examined in larger multicentre trials, both within and outside the USA. There is a case for countries outside the USA to survey their existing VR services to determine the extent to which the most effective interventions are being offered. ***DAY HOSPITAL VERSUS OUTPATIENT CARE FOR PATIENTS WITH PSYCHIATRIC DISORDERS*** BACKGROUND: This review considers the use of day hospitals as an alternative to outpatient care. Two typesof day hospital provision are covered: "day treatment programmes" and "day care centres". Day treatment programmes are day hospitals that are used to enhance the treatment of patients with anxiety or depressive disorders who have failed to respond to outpatient care. Day care centres are day hospitals that offer structured support to patients with long-term severe mental disorders who would otherwise be treated in an outpatient clinic. OBJECTIVES: There were two objectives: first, to assess the effectiveness of day treatment programmes versus outpatient care for people with non-psychotic disorders; and, secondly, to assess the effectiveness of day care centres versus outpatient care for people with severe long-term disorders. METHODS - STUDY SELECTION: Eligible studies were randomised controlled trials comparing day hospital care (either a day treatment programme or a day care centre) with outpatient care. Studies were ineligible if they were largely restricted to patients who were aged under 18 or over 65 years or who had a primary diagnosis of substance abuse or organic brain disorder. METHODS - DATA SOURCES: Relevant trials were identified from searches of the Cochrane Controlled Trials Register, MEDLINE, EMBASE, CINAHL, PsycLIT, and the reference lists of all identified studies and review articles. Researchers were approached to identify unpublished studies. Trialists were asked to provide individual patient data. METHODS - DATA EXTRACTION: All data were extracted independently by two reviewers and cross-checked. METHODS - DATA SYNTHESIS: Relative risks and 95% confidence intervals were calculated for dichotomous data. Standardised mean differences were calculated for continuous data. RESULTS: There was evidence from two of the five trials identified suggesting that day treatment programmes were superior to continuing outpatient care in terms of improving psychiatric symptoms. There was no evidence to suggest that day treatment programmes were better or worse than outpatient care on any other clinical or social outcome variable or on costs. (ABSTRACT TRUNCATED)

Creed F. · Department of Psychological Medicine, Manchester Royal Infirmary, United Kingdom. · Am J Med. · Pubmed #10588176 No free full text.

Abstract: This article reviews the evidence that psychiatric disorders have an adverse influence on the outcome of irritable bowel syndrome (IBS) and relates this to the close relationship between psychological symptoms and severity of abdominal pain, bloating, and diarrhea. Therefore, accurate measurement of psychological symptoms may be an important aspect of trial design for IBS therapy. The importance of psychological distress and health anxiety in differentiating "consulters" and "nonconsulters" for IBS is reviewed. The consequences of excluding from a trial people with certain types of psychiatric disorder or with a known past history of sexual abuse are considered.

Pitceathly C, Maguire P, Fletcher I, Parle M, Tomenson B, Creed F. · CRUK Psychological Medicine Group, Stanley House, Christie Hospital, Manchester, UK. · Ann Oncol. · Pubmed #19126633 No free full text.

Abstract: BACKGROUND: We tested whether a brief psychological intervention could prevent anxiety or depressive disorders among newly diagnosed cancer patients. PATIENTS AND METHODS: Patients free of anxiety or depressive disorder were randomised to receive immediate intervention (start of cancer treatment), delayed intervention (8 weeks after starting treatment) or usual care. They were stratified according to risk of developing anxiety or depressive disorders. Primary outcome was measured using a standardised psychiatric interview to detect any anxiety or depressive disorder at 6 and 12 months following the cancer diagnosis. Analyses used conditional odds logistic regression models adjusting for age, gender, concerns and past history to compare outcome of all intervention patients with usual care. RESULTS: A total of 465 patients were recruited. In all, 313 (79%) of the 397 well enough to be interviewed completed the study. At 12 months, there was no difference between the groups receiving the intervention and usual care [odds ratio (OR) = 0.69, 95% confidence interval (CI) 0.41-1.17, P = 0.17]. In high-risk patients, those who received the intervention were less likely to develop an anxiety or depressive disorder compared with those who received usual care (OR = 0.54, 95% CI 0.29-1.00, P = 0.050). In low-risk patients, there was no difference (OR = 1.50, 95% CI 0.51-4.43, P = 0.47). CONCLUSION: A brief intervention, delivered by nonspecialists, promoted adjustment among newly diagnosed cancer patients at high risk of developing anxiety or depressive disorders.

Dickens C, McGowan L, Percival C, Tomenson B, Cotter L, Heagerty A, Creed F. · Department of Psychiatry, University of Manchester, University Place, Oxford Road, Manchester M13 9PL, UK. · Gen Hosp Psychiatry. · Pubmed #18774424 No free full text.

Abstract: OBJECTIVE: To test the hypothesis that negative perceptions about heart disease at the time of the myocardial infarction (MI) were associated with the onset of new episodes of depression following MI. METHOD: We recruited 269 subjects admitted following first MI and monitored their depression status over the subsequent 12 months. At baseline, we recorded demographic information, family and personal history of cardiac disease and severity of MI; subjective health beliefs were assessed using the Illness Perceptions Questionnaire (IPQ). We assessed depression at baseline, 6 and 12 months following MI using a standardised questionnaire, validated in this population against a semistructured research interview. RESULTS: In the days following MI, patients who subsequently developed depression were more likely to anticipate that their heart disease would last a long time (P=.012) and was unlikely to be cured (P=.038). Controlling for potential confounding variables, scores on the IPQ remained associated with subsequent depression (P = .036), with anticipation that heart disease would last a long time [odds ratio (OR)=2.7, P=.013] and that heart disease could be cured (OR=0.45, P=.048) showing strongest association. CONCLUSIONS: Negative perceptions about heart disease in the days following admission to hospital with first MI are associated with the development of subsequent new episodes of depression.

Dickens C, McGowan L, Percival C, Tomenson B, Cotter L, Heagerty A, Creed F. · Department of Psychiatry, Rawnsley Building, Manchester Royal Infirmary, Oxford Road, Manchester M13 9WL. · Psychosom Med. · Pubmed #18434496 No free full text.

Abstract: OBJECTIVE: Studies investigating the effects of depression on mortality following myocardial infarction (MI) have produced heterogeneous findings. We report on a study investigating whether the timing of the onset of depression, with regard to the MI, affected its impact on subsequent cardiac mortality. METHODS: Five hundred and eighty-eight subjects admitted following MI underwent assessments of cardiac status, cardiac risk factors, and noncardiac illness. We identified separately subjects who were depressed before their MI (pre-MI depression) and those who developed depression in the 12 months after MI (new-onset depression), using a standardized questionnaire and a research interview. Patients dying of cardiac cause were identified during 8-year follow-up using information from death certificates. RESULTS: Multivariate predictors of cardiac death during follow-up included: greater age (hazards ratio (HR) = 1.06, p = .007), previous angina (HR = 4.15, p < .0005), high Killip Class (HR = 2.21, p = .013), prescription of beta-blockers on discharge (HR = 0.37, p = .02), and new-onset depression (HR = 2.33, p = .038). Pre-MI depression did not convey any additional risk of cardiac mortality. CONCLUSION: We have shown increased cardiac mortality in patients who develop depression after suffering MI. Further observational studies need to separate pre- and post-MI depression if we are to determine underlying mechanisms by which depression is associated with mortality following MI.

Creed F. · Manchester Royal Infirmary, Oxford Road, Manchester M13 9WL, UK. · World Psychiatry. · Pubmed #17139341 links to  free full text

Abstract: This paper examines the tendency for general psychiatry to ignore somatization and hypochondriasis. These disorders are rarely included in national surveys of mental health and are not usually regarded as a concern of general psychiatrists; yet primary care doctors and other physicians often feel let down by psychiatry's failure to offer help in this area of medical practice. Many psychiatrists are unaware of the suffering, impaired function and high costs that can result from these disorders, because these occur mainly within primary care and secondary medical services. Difficulties in diagnosis and a tendency to regard them as purely secondary phenomena of depression, anxiety and related disorders mean that general psychiatry may continue to ignore somatization and hypochondriasis. If general psychiatry embraced these disorders more fully, however, it might lead to better prevention and treatment of depression as well as helping to prevent the severe disability that may arise in association with these disorders.

Jackson J, Fiddler M, Kapur N, Wells A, Tomenson B, Creed F. · Division of Psychiatry, Medical School, University of Manchester, UK. · J Psychosom Res. · Pubmed #16581359 No free full text.

Abstract: BACKGROUND: In consecutive new outpatients, we aimed to assess whether somatization and health anxiety predicted health care use and quality of life 6 months later in all patients or in those without demonstrable abnormalities. METHOD: On the first clinic visit, participants completed the Illness Perception Questionnaire (IPQ), the Health Anxiety Questionnaire (HAQ), and the Hospital Anxiety and Depression Scale (HADS). Outcome was assessed as: (a) the number of medical consultations over the subsequent 6 months, extracted from medical records, and (b) Short-Form Health Survey 36 (SF36) physical component score 6 months after index clinic visit. RESULTS: A total of 295 patients were recruited (77% response rate), and medical consultation data were available for 275. The number of bodily symptoms was associated with both outcomes in linear fashion (P<.001), and this was independent of anxiety and depression. Similar associations were found in people with or without symptoms due to demonstrable structural abnormalities. Health anxiety was associated only with health-related quality of life in patients with symptoms explained by demonstrable abnormalities. CONCLUSION: The number of bodily symptoms and degree of health anxiety have different patterns of association with outcome, and these need to be considered in revising the diagnoses of somatization and hypochondriasis.

Creed F, Guthrie E, Ratcliffe J, Fernandes L, Rigby C, Tomenson B, Read N, Thompson DG, Anonymous00220. · School of Psychiatry and Behavioural Science, University of Manchester, Rawnsley Building, Oxford Road, Manchester M13 9WL, UK. · Aust N Z J Psychiatry. · Pubmed #16168039 No free full text.

Abstract: OBJECTIVE: We have previously reported improved health-related quality of life in patients with severe irritable bowel syndrome (IBS) following psychological treatments. In this paper, we examine whether this improvement was associated with improvement in psychological symptoms and was confined to those patients who had concurrent psychiatric disorder. METHOD: Two hundred and fifty-seven patients with severe IBS entering a psychological treatment trial were interviewed using the Schedules for Clinical Assessment in Neuropsychiatry. At entry to the trial and 15 months later, patients were also assessed using the Hamilton Depression Rating Scale, Symptom Cheecklist-90 (SCL-90) and Short Form-36 (SF36) physical component summary score as the main outcome measure. Partial correlation was used to compare changes in SF36 score and changes in psychological scores while controlling for possible confounders, treatment group and baseline scores. Multiple regression analysis was used to examine whether changes in psychological scores, changes in pain and a history of abuse could account for most of the variance of change in SF36 physical component score. RESULTS: Of 257 patients with severe IBS, 107 (42%) had a depressive, panic or generalized anxiety disorder at trial entry. There were moderate but significant correlations (0.21-0.47) between change in the psychological scores and the change in SF36 physical component scores. The correlation coefficients were similar in the groups with and without psychiatric disorder. The superiority of psychotherapy and antidepressant groups over treatment as usual was similar in those with and without psychiatric disorder. Multiple regression found significant independent effects of change in depression, anxiety, somatization and abdominal pain but there was still variance explained by treatment group. CONCLUSIONS: In severe IBS improvement in health-related quality of life following psychotherapy or antidepressants is correlated with, but not explained fully by reduction of psychological scores. A more complete understanding of how these treatments help patients with medically unexplained symptoms will enable us to refine them further.

Creed F, Ratcliffe J, Fernandes L, Palmer S, Rigby C, Tomenson B, Guthrie E, Read N, Thompson DG, Anonymous00204. · School of Psychiatry and Behavioural Science, University of Manchester, Oxford Road, Manchester M13 9WL, UK. · Br J Psychiatry. · Pubmed #15928362 links to  free full text

Abstract: BACKGROUND: Irritable bowel syndrome often leads to impaired functioning. AIMS: To assess the contribution of psychiatric disorders to impaired outcome in severe irritable bowel syndrome. METHOD: Patients with severe irritable bowel syndrome entering a psychological treatment trial (n=257) were interviewed using the Schedules for Clinical Assessment in Neuropsychiatry. Outcomes were number of days of restricted activity, role limitation (physical) score of the Short Form Health Survey and costs. RESULTS: At baseline, depressive disorder (29% of patients), panic (12%) and neurasthenia (35%) were associated with impairment; number of psychiatric disorders was associated in a dose-response fashion (P=0.005). At follow-up, depressive disorder and neurasthenia were associated with role limitation score. Improved depression was associated with improved role functioning. CONCLUSIONS: Depressive, panic and neurasthenic disorders contribute to poor outcomes in severe irritable bowel syndrome, and appropriate treatment should be available to these patients.

Jackson J, Kincey J, Fiddler M, Creed F, Tomenson B. · Psychological Medicine Research Group, Manchester Royal Infirmary, UK. · Br J Health Psychol. · Pubmed #15509353 No free full text.

Abstract: OBJECTIVES: This study aimed to assess whether patients with medically unexplained symptoms (MUS) attending cardiology and neurology out-patient clinics were less satisfied with their consultation than patients whose presenting symptoms were explained by an organic diagnosis. The multidimensional nature of satisfaction and its relationships with emotional distress and illness perception were also assessed within the two groups. DESIGN AND SETTING: A prospective cohort study was carried out at a large inner city teaching hospital. PARTICIPANTS: New attenders at cardiology and neurology out-patient clinics participated in the study. MEASURES: The Satisfaction Questionnaire, the Hospital Anxiety and Depression Scale (HADS), the Health Anxiety Questionnaire (HAQ) and the Illness Perception Questionnaire (IPQ) were used in the study. RESULTS: There were no overall significant differences in satisfaction between organic and MUS patients. Factor analysis yielded four factors: satisfaction with information, satisfaction with style of doctor-patient interaction, satisfaction with clinic environment, and satisfaction with patient's health. Levels of internal consistency were good, with Cronbach's alphas between .74 and .95 for the four subscales. CONCLUSION: When considering patients with MUS, these findings emphasize the need to examine healthcare satisfaction from a detailed and multidimensional perspective. Relationships between satisfaction dimensions, clinic specialties and measures of psychological well-being and of illness perception show interesting patterns. These findings raise both theoretical and service delivery questions concerning communication strategies.

Fiddler M, Jackson J, Kapur N, Wells A, Creed F. · Department of Psychiatry and Behavioural Sciences, University of Manchester, Manchester, UK. · Gen Hosp Psychiatry. · Pubmed #15474636 No free full text.

Abstract: We assessed possible psychological mediators of the relationship between childhood adversity and frequent medical consultations among new outpatients at neurology, cardiology, and gastroenterology clinics. We assessed whether these differed in patients with and without organic disease that explained their symptoms. At first clinic visit we recorded Hospital Anxiety and Depression scale (HADS--anxiety and depression subscale scores), Illness Perception Questionnaire (IPQ--four subscales: consequences, cure, identity, timeline), Health Anxiety Questionnaire (total score), and Symptom Amplification Scale (total score). Subjects were divided into two groups according to whether they had experienced any type of childhood adversity using the Childhood Experience of Care and Abuse Schedule. Outcome was the (log) number of medical consultations for 12 months before and 6 months after the index clinic visits. Multiple regression analysis was used to determine mediators; this was performed separately for patients with symptoms explained and not explained by organic disease. One-hundred and twenty-nine patients (61% response) were interviewed. Fifty-two (40.3%) had experienced childhood adversity; they made a median of 16 doctor visits compared with 10 for those without adversity (adjusted P=.026). IPQ identity score (number of symptoms attributed to the illness) and HAD depression scores were significantly associated with both childhood adversity and number of medical consultations and these variables acted as mediators between childhood adversity and frequency of consultation in the multiple regression analyses. This association was limited to patients with medically unexplained symptoms and was mediated by IPQ Identity Score (number of symptoms attributed to the patient's illness) and HAD depression score. Sexual abuse and overt neglect were the adversities most closely associated with frequent consultations. In patients with medically unexplained symptoms the association between childhood adversity and frequent medical consultations is mediated by the number of bodily symptoms attributed to the illness. Psychological treatments should be targeted at these patients with a view to reducing their frequent doctor visits.

Husain N, Gater R, Tomenson B, Creed F. · Institute of Psychiatry, Rawalpindi General Hospital, Rawalpindi, Pakistan. · Soc Psychiatry Psychiatr Epidemiol. · Pubmed #15300372 No free full text.

Abstract: OBJECTIVE: Previous studies have reported a high prevalence of depression in women in Pakistan. This paper investigates whether risk factors for chronic depression established in studies performed in Western countries can explain this high prevalence. METHOD: A two-phase survey using the self-rating questionnaire (SRQ) for common mental disorders and the Psychiatric Assessment Schedule was performed on a general population sample in rural Pakistan. Demographic data and results of the Life Events and Difficulties Schedule were analysed in relation to SRQ score and psychiatric disorder. RESULTS: A total of 145 women were screened. High SRQ score was associated with low educational status, not having a confidant, having four or more children, being older, not being married and living in a house with more than three people per room. Regression analysis demonstrated that the first three of these independently contributed to SRQ score. In the interviewed sample (74 women), only educational level independently contributed to the presence of depression. In addition, the least educated group experienced the greatest number of marked difficulties: 67% of them had experienced both marked housing and financial difficulties compared to 28% and 25% of the other educational groups (p = 0.005). Experiencing both housing and financial difficulties was a significant risk factor for depression in women with secondary education, but not for those without secondary education. CONCLUSIONS: This study suggests that high levels of social adversity and low levels of education are strongly associated with depression in women in Pakistan. The other vulnerability factors found in the West (such as lack of a confidant, the presence of three or more young children at home, or loss of mother during childhood) may be of lesser importance in this population.

Creed F, Barsky A. · University of Manchester, Manchester, UK. · J Psychosom Res. · Pubmed #15094023 No free full text.

Abstract: BACKGROUND: This paper reviews current knowledge regarding the prevalence and associated features of somatisation disorder and hypochondriasis in population-based and primary care samples. METHOD: A systematic review of the literature, which used a standardised definition of somatisation disorder or hypochondriasis and which examined the characteristics and associated features of these disorders in population-based samples or primary care settings. RESULTS: In population-based studies the prevalence of somatisation disorder and hypochondriasis was too low to examine associated features reliably. In studies using abridged criteria, a clear female predominance was not found in either disorder; there was a consistent relationship with few years of education. There was a close relationship with anxiety and depressive disorders, with a linear relationship between numbers of somatic and other symptoms of distress in several studies, including longitudinal studies. No studies showed that these symptom clusters fulfil the criteria of characteristic onset, course and prognosis required to merit the status of discrete psychiatric disorders. CONCLUSIONS: On existing evidence, somatisation disorder and hypochondriasis cannot be regarded as definite psychiatric disorders. There is some evidence that numerous somatic symptoms or illness worry may be associated with impairment and high health care utilisation in a way that cannot be solely explained by concurrent anxiety and depression, but further research using population-based samples is required.

Biggs AM, Aziz Q, Tomenson B, Creed F. · School of Psychiatry and Behavioural Sciences, Unit of Chronic Disease Epidemiology, Rawnsley Building, University of Manchester Medical School, Manchester Royal Infirmary, Oxford Road, Manchester M13 9PT, UK. · Gut. · Pubmed #14724147 links to  free full text

Abstract: BACKGROUND AND AIMS: This study assessed whether childhood and current adversities: (a) were more prevalent in patients with functional dyspepsia (FD) or non-cardiac chest pain (NCCP) than in patients with gastro-oesophageal reflux disease (GORD) or ischaemic heart disease (IHD); and (b) predicted health related quality of life in these disorders. PATIENTS: Cohort study of consecutive attenders to gastroenterology and cardiology clinics in a secondary/tertiary referral centre. METHODS: Patients were interviewed using the childhood experience of care and abuse and life events and difficulties schedules. Distress was assessed by questionnaire. Outcome was assessed using SF36 at the index clinic visit and six months later. RESULTS: A total of 133 patients were included (40 NCCP, 43 FD, 29 GORD, and 21 IHD) (67% response rate). The diagnostic groups did not differ significantly in the proportion reporting childhood adversity (30%), ongoing social stress (40%), lack of a close confidant (14%), or level of psychological distress. Reported childhood adversity was associated with poor outcome at the index visit (SF36 physical component score: 36.6 (SEM 1.8) v 42.3 (SEM 1.2) for the remainder; p = 0.014). In multiple regression analysis, childhood adversity was a significant independent predictor for patients with functional disorders (NCCP and FD) but not organic disorders (GORD or IHD). Change in SF36 score at six months was determined by age and distress score at the index visit in both groups. CONCLUSION: Childhood adversity was common among this consecutive sample but was associated directly with poor outcome only in patients with functional gastrointestinal syndromes. Distress is an important predictor of outcome in all patients. Greatest impairment occurs when lack of social support accompanies reported childhood adversity.

Biggs AM, Aziz Q, Tomenson B, Creed F. · School of Psychiatry and Behavioural Sciences, Rawnsley Building, Manchester Royal Infirmary, Manchester, UK. · Psychosom Med. · Pubmed #14645781 links to  free full text

Abstract: OBJECTIVE: A comprehensive model of health care use by patients with functional gastrointestinal disorders has not been fully tested. This study aimed to establish whether reported childhood and/or recent adversity are independent predictors of health care use when all other relevant factors are also included in the model. MATERIALS AND METHODS: Consecutive new patients with upper abdominal or chest pain presenting to a secondary/tertiary clinic were assessed using the Childhood Experience of Care and Abuse and Life Events and Difficulties Schedules. They completed the Hospital Anxiety and Depression and Health Anxiety Questionnaires. Outcome was total number of health care visits recorded in hospital and general practice (GP) records over 18 months. RESULTS: One hundred fifty-one patients were included (65% response rate). Health care visits were most frequent in unmarried (p < 0.0005), females (p < 0.0005), and those lacking social support (p = 0.012). In multiple regression analysis to predict number of health care visits, reported sexual abuse (p = 0.042) and death of a sibling during childhood (p = 0.026) were also independent predictors, together with SF36 subscale scores for physical function, health perception, and mental health (35% of variance explained). Childhood adversity predicted health care use in patients with functional gastrointestinal disorders and recent social stress did so in patients with demonstrated pathological findings. CONCLUSION: After adjustment for demographic, physical, and psychological factors, childhood adversity, especially in severe form, is an independent predictor of health care use in patients with upper functional gastrointestinal disorders. The same was not true for patients consulting for demonstrable pathological abnormalities, for whom ongoing social stress was an independent predictor.

Dickens C, Jackson J, Tomenson B, Hay E, Creed F. · School of Psychiatry and Behavioural Science, University of Manchester, Manchester, UK. · Psychosomatics. · Pubmed #12724502 links to  free full text

Abstract: This study assessed the relative strength of the association of physical characteristics and social stresses with a diagnosis of depression in patients with rheumatoid arthritis. Depression and social difficulties were assessed in 74 patients with rheumatoid arthritis by using standardized research interviews. Rheumatoid arthritis activity, damage related to rheumatoid arthritis, and subjective functional disability were assessed with well-validated methods. Twenty-nine patients (39.2%) were depressed. Compared to nondepressed patients, depressed patients had more marked social difficulties related to rheumatoid arthritis (72.4% versus 46.7%, respectively) and more marked social difficulties independent of rheumatoid arthritis (55.2% versus 31.1%, respectively). With logistic regression, social difficulties, independent of rheumatoid arthritis, was the only variable significantly associated with depression. Demographic characteristics and rheumatoid arthritis were not associated with a diagnosis of depression. Recognition by clinicians of the importance of social stresses, independent of disease state, should lead to more appropriate and specific psychological and social treatment of depression in rheumatoid arthritis.

Creed F, Morgan R, Fiddler M, Marshall S, Guthrie E, House A. · Psychological Medicine Research Group, University of Manchester, United Kingdom. · Psychosomatics. · Pubmed #12189256 links to  free full text

Abstract: Two hundred sixty-three consecutive medical inpatients were studied to assess whether depression and anxiety are associated with increased costs and reduced health-related quality of life. Seventy-three (27.8%) had depressive/anxiety disorders, 107 were "subthreshold" cases, and 83 were controls. After adjustment for severity of physical illness, using the Duke Severity of Illness Scale, cases and subthreshold cases incurred greater mean health care costs than controls over the follow-up period: $8,541 (SE = $605) versus $5,857 (SE = $859), P = 0.012. There was significant impairment of health-related quality of life (SF36 scores) in cases and, to a lesser extent, in subthreshold cases compared to controls. This impairment persisted at follow-up, as did anxiety and depression, indicating the need for future intervention studies.

Dickens C, Jayson M, Creed F. · Department of Psychiatry, Rawnsley Building, Manchester Royal Infirmary, Oxford Road, Manchester M13 9WL, UK. · Psychosomatics. · Pubmed #11927757 links to  free full text

Abstract: Pain behaviors that are excessive for the degree of known physical disease are common in patients with chronic low back pain and are frequently assumed to arise from a comorbid depressive illness. Although some studies have confirmed an association between depression and excessive pain behavior, methodologic problems (such as the use of depression ratings that also recorded symptoms attributable to physical disease) make interpretation of this finding difficult. We recruited 54 consecutive patients with chronic (>6 months) low back pain from a hospital clinic. Subjects completed self-rated assessments of anxiety and depression (Hospital Anxiety and Depression Scale) designed to be minimally affected by physical symptoms, along with assessments of disability (ODQ), pain (visual analogue scale), pain behavior (Waddell checklist), and physical impairment. Seventeen subjects (31%) exhibited excessive pain behavior. Overall, they were no more depressed or anxious than the remainder, although men with excessive pain behavior showed a trend toward being more depressed. Patients with excessive pain behavior were more disabled (self-rated and observer-rated), reported greater pain, and were more likely to be female and to have pain of shorter duration. Pain behavior did not correlate with anxiety or depression, but correlated with measures of disability and pain intensity. Factor analysis revealed that physical disability, pain intensity, and pain behavior loaded heavily on the first factor. Anxiety and depression loaded together on a separate factor. We conclude that pain behaviors were not related to anxiety or depression in our group, although gender differences between groups could have contributed to our negative findings. Pain behaviors may influence other physical measures. Further studies are required to investigate the relation between depression and pain behavior while controlling for gender differences.

Ronalds C, Kapur N, Stone K, Webb S, Tomenson B, Creed F. · Ladybarn Group Practice, Fallowfield, Manchester, University Department of Psychiatry, Manchester Royal Infirmary, Rusholme Health Centre, Manchester, UK. · Fam Pract. · Pubmed #11818346 links to  free full text

Abstract: BACKGROUND: Although it is recognized that anxiety and depression are associated with frequent attendance in primary care, not all patients with these disorders attend frequently. The factors associated with general practice consultation in the important group of patients with anxiety and depressive disorders are not clear. OBJECTIVES: Our aim was to determine prospectively the factors which predict consultation rate in a cohort of patients with anxiety and depressive disorders in primary care. METHODS: A total of 148 adult patients with a depressive, anxiety or panic disorder (DSM-III criteria) were studied prospectively for 6 months to determine the factors which predicted consultation rate during this time. Measures at baseline included: the Psychiatric Assessment Schedule, Hamilton Depression Rating Scale, Life Events and Difficulties Schedule, Clinical Anxiety Scale, details of substance misuse and demographic data. The principal outcome measure was the number of consultations recorded in the GP records over the following 6 months. The variables associated with consultation rate were assessed by multiple regression analysis, with number of consultations as the dependent variable. RESULTS: The median consultation rate during the 6 months of the study was five (range: 1-22). Thirty per cent of the sample consulted seven or more times during the 6 months and 10% consulted 12 or more times. The regression analysis demonstrated that the following variables contributed to the best model: prior consultation rate, past psychiatric history, ongoing social difficulties, current level of alcohol consumption, total psychiatric symptom score and total anxiety score. These variables together accounted for 41% of the variance in consultation rate. CONCLUSION: The detection and rigorous treatment of psychiatric disorder, the provision of social support and interventions for alcohol dependence may help to reduce the frequency of consultation of anxious and depressed patients in primary care. Future research to identify additional variables which explain the major part of the variance in consultation rate may pave the way for novel treatment approaches to the phenomenon of frequent attendance.

Weinberg A, Creed F. · Faculty of Health Care and Social Work Studies, University of Salford, UK. · Lancet. · Pubmed #10683003 No free full text.

Abstract: BACKGROUND: Previous studies of stress in healthcare staff have indicated a probable high prevalence of distress. Whether this distress can be attributed to the stressful nature of the work situation is not clear. No previous study has used a detailed interview method to ascertain the link between stress in and outside of work and anxiety and depressive disorders. METHODS: Doctors, nurses, and administrative and ancillary staff were screened using the general health questionnaire (GHQ). High scorers (GHQ>4) and matched individuals with low GHQ scores were interviewed by means of the clinical interview schedule to ascertain definite anxiety and depressive disorders (cases). Cases and controls, matched for age, sex, and occupational group were interviewed with the life events and difficulties schedule classification and an objective measure of work stress to find out the amount of stress at work and outside of work. Sociodemographic and stress variables were entered into a logistic-regression analysis to find out the variables associated with anxiety and depressive disorders. FINDINGS: 64 cases and 64 controls were matched. Cases and controls did not differ on demographic variables but cases were less likely to have a confidant (odds ratio 0.09 [95% CI 0.01-0.79]) and more likely to have had a previous episode of psychiatric disorder (3.07 [1.10-8.57]). Cases and controls worked similar hours and had similar responsibility but cases had a greater number of objective stressful situations both in and out of work (severe event or substantial difficulty in and out of work-45 cases vs 18 controls 6.05 [2.81-13.00], p<0.001; severe chronic difficulty outside of work-27 vs 8, 5.12 [2.09-12.46], p<0.001). Cases had significantly more objective work problems than controls (median 6 vs 4, z=3.81, p<0.001). The logistic-regression analyses indicated that even after the effects of personal vulnerability to psychiatric disorder and ongoing social stress outside of work had been taken into account, stressful situations at work contributed to anxiety and depressive disorders. INTERPRETATION: Both stress at work and outside of work contribute to the anxiety and depressive disorders experienced by healthcare staff. Our findings suggest that the best way to decrease the prevalence of these disorders is individual treatment, which may focus on personal difficulties outside of work, combined with organisational attempts to reduce work stress. The latter may involve more assistance for staff who have a conflict between their managerial role and clinical role.

Harrison J, Barrow S, Gask L, Creed F. · Department of Psychiatry, Central Manchester Healthcare NHS Trust. · J Public Health Med. · Pubmed #10528955 links to  free full text

Abstract: BACKGROUND: To develop interventions to reduce the morbidity associated with depression and anxiety, more information is needed about the social and demographic determinants of these disorders and the relative contributions of different potential predictors. METHODS: Using stratified sampling from the Family Health Services Authority (FHSA) register, postal surveys were sent to 61,000 adults across the North Western Regional Health Authority. Psychological morbidity was assessed using the 12-item General Health Questionnaire (GHQ). Nine potential predictors of morbidity were rated, including socio-demographic details and the presence of longstanding limiting physical illness and of a confidante. Logistic regression analyses were used to consider each of the nine potential predictors separately and in combination. RESULTS: A total of 38,014 questionnaires were returned (63 per cent). After adjustment for all other variables the strongest predictors of a high GHQ score were the absence of a confidante (odds ratio (OR) 3.64), longstanding limiting physical illness (OR 2.93), unemployment (OR 1.91), being a student (OR 1.78), being female (OR 1.64), single parenthood (OR 1.55) and living alone (OR 1.32). GHQ scores were highest in the 18-34 age range. Ethnicity exerted no significant effect after adjustment for other variables. CONCLUSION: In keeping with other research the data suggest that sociodemographic factors are strong predictors of depression and anxiety. The most vulnerable population groups are those with longstanding limiting physical illness and no-one to talk to. This should help in identifying high-risk individuals and informing preventive strategies.

Creed F, Winterbottom M, Tomenson B, Britt R, Anand IS, Wander GS, Chandrashekhar Y. · Department of Psychiatry, University of Manchester, UK. · Acta Psychiatr Scand. · Pubmed #10223427 No free full text.

Abstract: OBJECTIVE: The prevalence of anxiety and depressive disorders in people of South Asian origin in the UK is not accurately known. METHOD: A population-based study of UK residents from the Indian subcontinent was screened for anxiety and depressive disorders with the Self-Rating Questionnaire (SRQ) and for life events using the brief list of threatening life events. Similar measures were administered to siblings in India. RESULTS: The UK sample included 223 Sikhs, 100 Hindus and 49 Muslims. Elevated SRQ scores were recorded in 5%, 13% and 23%, respectively, of men from these groups and in 16%, 27% and 57%, respectively, of females. Subjects reporting one or more threatening life events (most commonly unemployment and financial problems) also had raised SRQ scores. A total of 117 siblings in India reported similar SRQ scores to their index subjects in the UK, but reported more threatening life events, notably deaths and illness in the family and financial problems. CONCLUSION: This preliminary study indicates that psychiatric disorder in ethnic groups varies across religious groups. The prevalence may be high in some religious groups in association with social difficulties. The patterns of stress in India and the UK are different.