The rationale for the development of Repertory-Grid based quality of life assessment (QOL) is described. The emergent scale, the SmithKline Beecham Quality of Life Scale (SBQOL) utilizes 23 predetermined constructs and three fixed elements: self now, ideal self and sick self. Inclusion of the latter two elements provides a personal frame of reference for the individual and recognizes the highly idiosyncratic and subjective nature of the experience which constitutes quality of life. A study of the validity and reliability of the SBQOL was conducted in 129 patients presenting to their GP with either major depression or generalized anxiety disorder, as defined by DSM III R. Patients were treated at the discretion of their GP and followed over a period of 12 weeks with assessments of treatment efficacy being performed at 6 weeks and 12 weeks in parallel with administration of the SBQOL. The results from co-administration of standard efficacy measures such as the Hamilton Depression Rating Scale (HAMD) and Hamilton Anxiety Scale (HAMA) with the SBQOL, provided good evidence of construct validity. Evidence in support of the concurrent validity of the SBQOL was provided by co-administration of the Sickness Impact Profile and General Health Questionnaire (external criteria) with the SBQOL scale. Test-retest reliability and internal consistency were high. No obvious advantage was conferred by the use of principal components analysis from the Flexigrid software package in contrast to a simple arithmetical procedure for computing interelement distances. It is concluded that the SBQOL provides a valid, reliable and practicable approach to the assessment of quality of life in patients with affective disorder.
Considerable attention has been paid, both by regulatory authorities and clinicians, to the side-effects of antidepressants, but despite the known high suicide risk in depression, toxicity in overdosage has been largely ignored. On the basis of the evidence currently available, 'older' antidepressants appear to be more toxic than 'newer' agents. A case can be made for limiting the use of some of the older tricyclic antidepressants, especially in patients who remain in the community, when continuous supervision is lacking, in favour of newer, safer drugs.
Schizophrenia is a debilitating mental disorder affecting up to five in every thousand people. Although specialist psychiatrists are initially responsible for treating patients suffering from acute schizophrenia, the current structure of mental healthcare in the U.K. puts the onus for the delivery of maintenance therapy of discharged patients on to the general practitioner. It is crucial, therefore, that the general practitioner is aware of all available therapies for the effective, long-term, community-based treatment of patients with schizophrenia. The so-called typical antipsychotics effectively treat the positive but not the negative symptoms of schizophrenia, and up to 40% of patients are nonresponders. These antipsychotics, however, are associated with high levels of extrapyramidal side-effects (EPS), which are the main cause of patient non-compliance and their subsequent relapse and hospital readmission. Clozapine, the first atypical antipsychotic, may cause severe agranulocytosis and patients must undergo regular haematological monitoring, which is both costly and a factor unlikely to foster patient compliance. In contrast, newly developed atypical antipsychotics, such as olanzapine and quetiapine, are not only efficacious in treating the symptoms of schizophrenia, but also give rise to fewer EPS and are generally better tolerated than clozapine. In particular, olanzapine and quetiapine are not associated with severe agranulocytosis. Atypical antipsychotics, therefore, have the potential to enhance patient compliance and thus ease the general practitioner's problems of providing long-term and effective treatment for patients with schizophrenia.
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