Jonathan Price

Background: Mood instability is a common reason for psychiatric referral. Very little is known about how patients with unstable mood experience assessment and diagnosis.Aims: To investigate the experiences of assessment and diagnosis among patients with mood instability and to suggest improvements to this process.Method: Qualitative study, gathering data through individual interviews with 28 people experiencing mood instability and receiving a psychiatric assessment in secondary care.Results: Participants described the importance of receiving an explanation for their symptoms; the value of a good interpersonal relationship with their clinician(s); being listened to and acknowledged; and being involved in and informed about clinical decisions. These needs were not, however, consistently met. Receiving a psychiatric diagnosis, including a diagnosis of bipolar disorder or borderline personality disorder, evoked both positive and negative responses among participants, relating to stigma, personal understanding and responsibility, prognosis and treatment.Conclusions: Patients with mood instability seek explanation for their symptoms and difficulties, empathetic care and consistent support as much as cure. Clinicians may incorrectly assume what patients' attitudes towards diagnosis are, a mismatch which may hamper the development of a strong therapeutic relationship. Clear, patient-centred communication, which acknowledges the patient's experience, may result in greater patient engagement and satisfaction.

Background: Some people who take selective serotonin reuptake inhibitor (SSRI) antidepressants report that their experience of emotions is ‘blunted’. This phenomenon is poorly understood.Aims: To understand patients' experiences of this phenomenon.Method: Qualitative study, gathering data through individual interviews, a group interview and validation interviews; and searching patient websites for relevant posts.Results: There was strong evidence that some people taking SSRIs experience significant emotional symptoms that they strongly attribute to their antidepressant. These emotional symptoms can be described within six key themes. A seventh theme represents the impact of these side-effects on everyday life, and an eighth represents participants' reasons for attributing these symptoms to their antidepressant. Most participants felt able to distinguish between emotional side-effects of antidepressants and emotional symptoms of their depression or other illness.Conclusions: Emotional side-effects of SSRIs are a robust phenomenon, prominent in some people's thoughts about their medication, having a demonstrable impact on their functioning and playing a role in their decision-making about antidepressant adherence.

Chronic fatigue syndrome (CFS) is a common, debilitating and serious health problem. Cognitive behaviour therapy (CBT) may help to alleviate the symptoms of CFS. To examine the effectiveness and acceptability of CBT for CFS, alone and in combination with other interventions, compared with usual care and other interventions. CCDANCTR‐Studies and CCDANCTR‐References were searched on 28/3/2008. We conducted supplementary searches of other bibliographic databases. We searched reference lists of retrieved articles and contacted trial authors and experts in the field for information on ongoing/completed trials. Randomised controlled trials involving adults with a primary diagnosis of CFS, assigned to a CBT condition compared with usual care or another intervention, alone or in combination. Data on patients, interventions and outcomes were extracted by two review authors independently, and risk of bias was assessed for each study. The primary outcome was reduction in fatigue severity, based on a continuous measure of symptom reduction, using the standardised mean difference (SMD), or a dichotomous measure of clinical response, using odds ratios (OR), with 95% confidence intervals (CI). Fifteen studies (1043 CFS participants) were included in the review. When comparing CBT with usual care (six studies, 373 participants), the difference in fatigue mean scores at post‐treatment was highly significant in favour of CBT (SMD ‐0.39, 95% CI ‐0.60 to ‐0.19), with 40% of CBT participants (four studies, 371 participants) showing clinical response in contrast with 26% in usual care (OR 0.47, 95% CI 0.29 to 0.76). Findings at follow‐up were inconsistent. For CBT versus other psychological therapies, comprising relaxation, counselling and education/support (four studies, 313 participants), the difference in fatigue mean scores at post‐treatment favoured CBT (SMD ‐0.43, 95% CI ‐0.65 to ‐0.20). Findings at follow‐up were heterogeneous and inconsistent. Only two studies compared CBT against other interventions and one study compared CBT in combination with other interventions against usual care. CBT is effective in reducing the symptoms of fatigue at post‐treatment compared with usual care, and may be more effective in reducing fatigue symptoms compared with other psychological therapies. The evidence base at follow‐up is limited to a small group of studies with inconsistent findings. There is a lack of evidence on the comparative effectiveness of CBT alone or in combination with other treatments, and further studies are required to inform the development of effective treatment programmes for people with CFS. 成人慢性疲勞症候群的認知行為治療 慢性疲勞症候群(簡稱CFS)是一種常見，虛弱和嚴重的健康問題。認知行為治療(CBT)可能有助於減輕CFS的症狀 檢視CBT對CFS治療的有效性與接受度，採單獨使用或結合其他處遇措施，並與一般照護以及其他處遇措施做比較。 28/3/2008搜尋CCDANCTRStudies and CCDANCTRReferences。我們額外搜尋其他書目資料庫。我們搜尋了文章檢索理得參考文獻清單，與這些試驗的作者及該領域的專家聯繫，取得正在進行或已完成試驗的資訊。 選擇主要診斷為CFS,並且分派使用CBT或一般照護或其他處遇(不論單獨或合併)治療的隨機對照試驗。 由兩名審查者獨立抽出病人的資料，處遇措施與結果，每個研究都進行偏誤(bias)風險評估。主要的預後評估是疲勞減少程度,對於症狀減輕的連續變項會計算standardised mean difference (SMD), 而對於二分變項,則會去計算 odds ratios (OR)並附上95% confidence intervals (CI). 納入15個研究(共1043名CFS患者參與)。在比較CBT與一般照護(6項研究，373名參與者)上，治療後疲勞分數的平均數在CBT組呈現明顯改善(SMD −0.39, 95% CI在 −0.60 到 −0.19之間)，CBT組有40%的人有臨床反應而在常規照護則只有26%(4項研究，371名參與者)(OR 0.47, 95% CI 在0.29到0.76之間)，但在後續追蹤時結果卻呈現不一致。 相較於CBT與其他心理治療，包括放鬆，諮商和教育/支持(4項研究，313名參與者)，在治療後疲勞的平均分數，CBT組同樣優於其他組別(SMD −0.43, 95% CI −0.65 到 −0.20之間)，不過同樣地，後續追蹤的結果分歧而不一致。 有兩個研究比較CBT處置與其他另外的處遇方式，有一個研究比較CBT合併其他處遇方式與一般照護的差異。 與一般照護相較之下，CBT能有效地減少治療後的疲勞症狀，而與其他心理療法比較下，也可能可以減少疲勞症狀。但在後續追蹤研究上卻因為研究不多以及結果不一致而使得證據力薄弱。此外，對於比較單獨使用CBT或結合CBT與其他治療方式的研究則付之闕如，未來還需要更進一步的研究以便發展出有效治療疲勞症狀的方法。 本摘要由彰化基督教醫院陳美貴翻譯。 此翻譯計畫由臺灣國家衛生研究院(National Health Research Institutes, Taiwan)統籌。 慢性疲勞綜合徵(簡稱CFS)是一種非常普遍及失能的狀態，人們會持續出現不明原因的疲勞。認知行為療法是一種心理治療模式，通常用於治療各種心理和慢性疼痛。本次文獻回顧的目的是查明在CFS的治療上，是否CBT是有效的，不論是單獨使用或合併其他治療，是否比其他治療更有效。 文獻回顧內容包括15項研究，總共1043的參與者。回顧結果，發現與一般照護及等候治療者相較之下，以CBT治療較能減少疲勞症狀。CBT組有40%的人有臨床反應而在常規照護則只有26%。在後續追蹤方面，在治療後1 –...

Objective  To describe the attitudes that women with chronic pelvic pain (CPP) attending gynaecology clinics have to their consultations and to determine the ways in which their health care can be improved.Design  Qualitative study using semistructured individual interviews.Setting  UK gynaecology outpatient clinics in district general and teaching hospitals.Sample  Twenty‐six women with CPP.Methods  Semistructured individual interviews were conducted. Data gathering and analysis followed a grounded theory approach.Main outcome measures  Women's wishes regarding their care and their actual experiences of care.Results  Four main themes emerged. The women wanted (a) personal care, which they often did not receive; (b) to feel understood and to be taken seriously, although they often felt dismissed, which applied both to women with and without an explanation for their pain; (c) explanation as much as cure, but an adequate explanation was often not provided; and (d) to be reassured, which often they were not. Effective reassurance was complex as it included general reassurance and specific reassurance about cause and treatment.Conclusions  Improvements are needed in the outpatient care of women presenting with CPP. Changes should focus on providing more personal care, so that presenting problems are seen to be taken seriously, findings and management are appropriately explained, and women are more effectively reassured. Interventions need to be developed that meet these needs and tested to determine if they are feasible, acceptable, and improve outcomes.

Chronic fatigue syndrome (CFS) is an illness characterised by persistent medically unexplained fatigue. CFS is a serious health-care problem with a prevalence of up to 3%. Treatment strategies for CFS include psychological, physical and pharmacological interventions. To investigate the relative effectiveness of exercise therapy and control treatments for CFS. CCDANCTR-Studies and CENTRAL were searched using "Chronic Fatigue" and Exercise. The Journal of Chronic Fatigue Syndrome and CFS conferences were handsearched. Experts in the field were contacted. Clinicaltrials.gov and controlled-trials.com were searched. Only Randomised Controlled Trials (RCT) including participants with a clinical diagnosis of CFS and of any age were included. The full articles of studies identified were inspected by two reviewers (ME and HMG). Continuous measures of outcome were combined using standardised mean differences. An overall effect size was calculated for each outcome with 95% confidence intervals. One sensitivity analysis was undertaken to test the robustness of the results. Nine studies were identified for possible inclusion in this review, and five of those studies were included. At 12 weeks, those receiving exercise therapy were less fatigued than the control participants (SMD -0.77, 95% CIs -1.26 to -0.28). Physical functioning was significantly improved with exercise therapy group (SMD -0.64, CIs -0.96 to -0.33) but there were more dropouts with exercise therapy (RR 1.73, CIs 0.92 to 3.24). Depression was non-significantly improved in the exercise therapy group compared to the control group at 12 weeks (WMD -0.58, 95% CIs -2.08 to 0.92). Participants receiving exercise therapy were less fatigued than those receiving the antidepressant fluoxetine at 12 weeks (WMD -1.24, 95% CIs -5.31 to 2.83). Participants receiving the combination of the two interventions, exercise + fluoxetine, were less fatigued than those receiving exercise therapy alone at 12 weeks, although again the difference did not reach significance (WMD 3.74, 95% CIs -2.16 to 9.64). When exercise therapy was combined with patient education, those receiving the combination were less fatigued than those receiving exercise therapy alone at 12 weeks (WMD 0.70, 95% CIs -1.48 to 2.88). There is encouraging evidence that some patients may benefit from exercise therapy and no evidence that exercise therapy may worsen outcomes on average. However the treatment may be less acceptable to patients than other management approaches, such as rest or pacing. Patients with CFS who are similar to those in these trials should be offered exercise therapy, and their progress monitored Further high quality randomised studies are needed.