Serious mental illness and physical health problems: a discussion paper.

Depression in adults with a chronic physical health problem: treatment and management.

OBJECTIVE: Patients with depression present with psychological and somatic symptoms, including general aches and pains. In primary care, somatic symptoms often dominate. A review of the literature was conducted to ascertain the importance of somatic symptoms in depression in primary care. DATA SOURCES AND EXTRACTION: MEDLINE, EMBASE, and PsychLIT/PsychINFO databases (1985-January 2004) were searched for the terms depression, depressive, depressed AND physical, somatic, unexplained symptoms, complaints, problems; somatised, somatized symptoms; somatisation, somatization, somatoform, psychosomatic; pain; recognition, under-recognition; diagnosis, underdiagnosis; acknowledgment, under-acknowledgment; treatment, undertreatment AND primary care, ambulatory care; primary physician; office; general practice; attribution, re-attribution; and normalising, normalizing. Only English-language publications and abstracts were considered. STUDY SELECTION: More than 80 papers related to somatic symptoms in depression were identified using the content of their titles and abstracts. DATA SYNTHESIS: Approximately two thirds of patients with depression in primary care present with somatic symptoms. These patients are difficult to diagnose, feel an increased burden of disease, rely heavily on health care services, and are harder to treat. Patient and physician factors that prevent discussion of psychological symptoms during consultations must be overcome. CONCLUSIONS: Educational initiatives that raise awareness of somatic symptoms in depression and help patients to re-attribute these symptoms should help to improve the recognition of depression in primary care.

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The importance of somatic symptoms in depression in primary care.

Background. Auditory hallucinations in psychosis often contain critical evaluations of the voice-hearer (for example, attacks on self-worth). A voice-hearer's experience with their dominant voice is a mirror of their social relationships in general, with experiences of feeling low in rank to both voices and others being associated with depression. However, the direction of the relationship between psychosis, depression and feeling subordinate is unclear.Method. Covariance structural equation modelling was used with data from 125 participants diagnosed with schizophrenia to compare three ‘causal’ models: (1) that depression leads to the appraisal of low social rank, voice power and distress; (2) that psychotic illness leads to voice activity (frequency, audibility), which in turn leads to depression and the appraisal of voices' power; (3) our hypothesized model, that perceptions of social rank and social power lead to the appraisal of voice power, distress and depression.Results. Findings supported model 3, suggesting that the appraisal of social power and rank are primary organizing schema underlying the appraisal of voice power, and the distress of voices.Conclusions. Voices can be seen to operate like external social relationships. Voice content and experience can mirror a person's social sense of being powerless and controlled by others. These findings suggest important new targets for intervention with cognitive and social therapy.

https://www.cambridge.org/core/services/aop-cambridge-core/content/view/S0033291704002636

Interpersonal and role-related schema influence the relationship with the dominant 'voice ' in schizophrenia : a comparison of three models

Voice hearing (VH) is often regarded as pathognomic for schizophrenia. The purpose of this article is to review and integrate historical, clinical, epidemiological, and phenomenological evidence in order to suggest that VH may be more appropriately understood as a dissociative rather than a psychotic phenomenon. First, we discuss the lifetime prevalence of VH in the general population, which is estimated to range between 1% and 16% for adult nonclinical populations and 2% and 41% in healthy adolescent samples. Second, we demonstrate how the ubiquity of VH phenomenology, including variables like voice location, content, and frequency, limits its diagnostic and prognostic utility for differentiating psychotic from trauma-spectrum and nonclinical populations. Finally, we report on the empirical associations between VH, measures of dissociation, and trauma particularly (though not exclusively) childhood sexual abuse. There are 2 main conclusions from this review. First, we argue that available evidence suggests that VH experiences, including those in the context of psychotic disorders, can be most appropriately understood as dissociated or disowned components of the self (or self-other relationships) that result from trauma, loss, or other interpersonal stressors. Second, we provide a rationale for clinicians to use psychotherapeutic methods for integrating life events as precipitating and/or maintaining factors for distressing voices. Potential mechanisms for the relationship between trauma, dissociation, VH, and clinical diagnosis are described, including the relevance of literature from the field of attachment in providing a diathesis for dissociation. Suggestions for future research are also discussed.

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Dissociation, Trauma, and the Role of Lived Experience: Toward a New Conceptualization of Voice Hearing.

Journal of Advanced Nursing 31(5),1199–1205Beliefs about voices and their effects on coping strategiesCognitive behavioural techniques are increasingly used as adjuncts to medica-tion in the treatment of auditory hallucinations for people with schizophrenia.There are now literally hundreds of nurses trained in the use of cognitivebehavioural interventions for psychosis. However, there is still disagreementabout the nature of the cognitive processes that lead to deﬁcits or biases inpatients’ processing of information about their psychotic experiences. UsingChadwick & Birchwood’s Beliefs About Voices Questionnaire (BAVQ), theinvestigator collected data regarding voices from a sample of men and womenbeing treated for schizophrenia by secondary mental health services. Theinvestigator then carried out a cross-lagged panel analysis of the data. Theinvestigator found, as predicted, positive relationships between a resistivecoping style and an attribution of malevolence to voices, and between anengaging coping style and an attribution of benevolence to voices. Coping andattributional styles were not necessarily stable over time. There was anon-signiﬁcant difference between women’s and men’s attributions and copingstyles. There was less ﬂuctuation over time in the women’s scores on the BAVQ.This research shows that one cannot assume that either coping or attributionalstyle becomes more stable over time. However, while there are strongrelationships between attributions and coping styles, and particularly betweenmalevolence and resistance and benevolence and engagement, theserelationships are not necessarily mutually exclusive and some people in thestudy believe their voices to be both malevolent and benevolent. These ﬁndingssuggest that clinicians need to make a very careful assessment of attribution andcoping with regard to hallucinations and that systematic reassessment is veryimportant. Further research is necessary in both the phenomenology of

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Beliefs about voices and their effects on coping strategies

Background The general practitioner (GP) has traditionally been the first port of call for people with psychiatric morbidity but increasingly other members of the primary care team see the patients first, particularly practice nurses The numbers and roles of practice nurses have expanded greatly over the past decade and it is important that practice nurses are able to recognize patients with psychiatric morbidity This paper reports a study to determine the abilities of 24 practice nurses to detect psychiatric morbidity in patients attending their clinics Methods Twenty-four practices were randomly selected from 41 practices recruited from South London and Kent One nurse per practice took part in the study Patients were asked to complete a 12-item General Health Questionnaire (GHQ-12) while waiting for their appointment with the practice nurse Following their consultation, the practice nurse rated the patients' level of psychological distress on a five-point rating scale Results The response rate of patients was 97% (N= 1710) The GHQ case rate was 36% The mean detection rate by practice nurses when identifying significant distress was 16% (between nurse variation, 0% to 61%) The mean specificity was 96% (variation 77% to 100%) A second analysis, changing the nurse criterion to recognition of distress increased the mean sensitivity rate to 58% (variation 31% to 84%) but the mean specificity rate decreased to 66% (variation 26% to 95%) Conclusions These results demonstrate that practice nurses' caseloads include a high proportion of patients with psychiatric morbidity and that agreement with the GHQ classification of psychiatric morbidity is modest Therefore, training in detection will be crucial for the nurses

Detection of psychological distress by practice nurses in general practice.

A national survey of practice nurse involvement in mental health interventions



Background: The move in the United Kingdom (UK) from institutional to community care has led to an inevitable increase in the involvement of practice nurses (PNs) in mental health care. Around 20 000 PNs are currently working in the United Kingdom (UK). However, the extent and nature of PN involvement in delivering mental health interventions has not been adequately explored. Aim: This study aimed to quantify practice nurses’ involvement in delivering mental health interventions in primary care settings. Method: A questionnaire was sent to a random sample of 1500 practice nurses registered with the Practice Nurse Forum at the Royal College of Nursing. Sixty per cent of questionnaires were returned; however, once non-eligible respondents were removed an adjusted response rate of 54% was achieved. Results: Practice nurses play a significant role in the assessment and treatment of mental health problems, most frequently via the administration of depot antipsychotics and the screening for depression. However, antipsychotic side-effects were infrequently monitored and PNs’ understanding of treatment issues in depression is poor. These findings may be associated with the reported lack of mental health training that PNs have received. Conclusions: The findings of this study have important implications for the training of practice nurses in mental health, specifically in the areas of medication management and the detection of mental disorders.

A national survey of practice nurse involvement in mental health interventions

Recording skills practice on videotape can enhance learning — a comparative study between nurse lecturers and nursing students



Video recording techniques have been used in educational settings for a number of years. They have included viewing video taped lessons, using whole videos or clips of tapes as a trigger for discussion, viewing video recordings to observe role models for practice, and being video recorded in order to receive feedback on performance from peers and tutors. Although this last application has been in use since the 1960s, it has only been evaluated as a teaching method with health care professionals in the past 10 years and mostly in the areas of medical and counsellor education. In nurse education, however, use of video recording techniques has been advocated without any empirical evidence on its efficacy. This study has used nursing degree students and nurse educationalists to categorize statements from four cohorts of students who took part in a 12-day clinical supervision course during which their interpersonal skills were recorded on videotape. There were two categories: positive and negative/neutral. Analysis of the data showed that between 61% and 72% of the subjects gave an overall positive categorization to the statements in the questionnaire. Chi-square tests were significant for all groups in both categories. This suggests that both nursing students and nurse lecturers thought that course participants’ statements expressed a positive belief that video tape recording is useful in enhancing students’ ability to learn effective interpersonal skills in clinical supervision.

Susan Ritter

Papers

Beliefs about voices and their effects on coping strategies

Detection of psychological distress by practice nurses in general practice.

A national survey of practice nurse involvement in mental health interventions

Recording skills practice on videotape can enhance learning - a comparative study between nurse lecturers and nursing students.