Psychological disorders are highly prevalent in patients with inflammatory bowel disease (IBD). Anxiety and depression are known to independently affect quality of life and may additionally impair quality of life in IBD over and above the IBD itself. Some researchers have further proposed that anxiety and depression may influence the clinical course of IBD. However, despite the potential for anxiety and depression to play an important role in the clinical picture of IBD, there is little prospective well-controlled research in this area. Probably because of this lack of clear data, researchers dispute the actual role of these psychological disorders in IBD, with a number of conflicting opinions expressed. This article reports on a review of the literature in this field. Herein we discuss the five main areas of controversy regarding IBD and the specific psychological comorbidities of depression and anxiety: 1) the relative rate of cooccurrence of these psychological disorders with IBD; 2) the cooccurrence of these psychological disorders with particular phase of IBD; 3) the cooccurrence of these psychological disorders with the specific type of IBD; 4) the rate of these psychological comorbidities compared both to healthy subjects and to other disease states; and 5) the timing of onset of psychological comorbidity with respect to onset of IBD. Methodological weaknesses of the reviewed studies make it impossible to resolve these controversies. However, the results clearly show that anxiety/depression and IBD frequently interact. Given the long-term illness burden patients with IBD face, further prospective, appropriately controlled studies are needed to adequately answer the question of the precise interplay between anxiety/depression and IBD.

Theories from social and behavioural science can make an important contribution to the process of developing a conceptual framework for improving use of clinical practice guidelines and clinician performance. A conceptual framework for guideline dissemination and implementation is presented which draws on relevant concepts from diVusion of innovation theory, the transtheoretical model of behaviour change, health education theory, social influence theory, and social ecology, as well as evidence from systematic literature reviews on the eVectiveness of various behaviour change strategies. The framework emphasises the need for preimplementation assessment of (a) readiness of clinicians to adopt guidelines into practice, (b) barriers to change as experienced by clinicians, and (c) the level at which interventions should be targeted. It also incorporates the need for multifaceted interventions, identifies the type of barriers which will be addressed by each strategy, and develops the concept of progression through stages of guideline adoption by clinicians, with the use of appropriately targeted support strategies.The potential value of the model is that it may enable those involved in the process of guideline dissemination and implementation to direct strategies to target groups more eVectively. Clearly, the eVectiveness and utility of the model in facilitating guideline dissemination and implementation requires validation by further empirical research. Until such research is available, it provides a theoretical framework that may assist in the selection of appropriate guideline dissemination and implementation strategies. (Quality in Health Care 1999;8:177-183) Keywords: guidelines; behaviour change theory; conceptual framework Until recently, there has been little research on the relative merits of dissemination and implementation strategies used to encourage adoption of clinical practice guidelines. However, evidence now exists that use of an appropriate range of strategies, beyond simple information provision through publication in journals or general mailings, can significantly increase rates of guideline adoption by clinicians.

BackgroundWhether there is a temporal relationship between psychological problems and clinical outcomes in patients with diseases of the digestive tract has not been widely researched. Thus, our aims were 1) To observe and compare prospectively clinical outcomes in relation to psychological co-morbidity in patients with inflammatory bowel disease (IBD), irritable bowel syndrome (IBS) and chronic hepatitis C (HCV) and, 2) To test the hypothesis that patients with psychological co-morbidities are less likely to have a satisfactory response to standard treatment at 12 months.MethodsOverall, 139 patients were enrolled in this observational cohort prospective study. Over the ensuing year, physical and psychological measures were made at baseline and after 12 months (HADS, SCL90, SF-12 and disease activity measures). A logistic regression was conducted to observe any relationship between baseline characteristics and patients' clinical outcomes after 12 months.ResultsOverall, there was no relationship between psychological status and quality of life at baseline and relapse at 12 months (p > 0.05). However, patients with inactive disease at baseline were at lower risk of relapse after 12 months (OR = 0.046, CI: 0.012–0.178). No significant relationship was found between psychological problems such as depression/anxiety and a total number of relapses in the IBD group. However, interestingly, patients with an active disease at baseline tended to have a greater number of relapses (OR = 3.07, CI: 1.650–5.738) and CD participants were found at lower risk of relapse than UC participants (OR = 0.382, CI: 0.198–0.736).ConclusionIn contrast to previous investigations, this study suggests that there is no temporal relationship between psychological problems at baseline and clinical outcomes over time. Longer and larger prospective studies are needed to better understand this result.

BackgroundIn independent studies, IBD, IBS and HCV have each been associated with a substantially increased risk of psychological problems such as depression and anxiety and impairment of quality of life compared to the general healthy population. However, the relative psychological burden for each of these diagnoses is unknown as it has never been compared contemporaneously at one institution. Current local data are therefore needed to enable an evidence-based allocation of limited clinical psychological resources.MethodsOverall, 139 outpatients (64 IBD, 41 HCV, and 34 IBS) were enrolled in this cross-sectional study. The HADS, SCL90, SF-12 and appropriate disease-specific activity measures were administered. Differences between groups were assesed with ANOVA, the Chi-Square test and the independent samples t-test (two-tailed).ResultsEach of the three groups had significantly lower quality of life than the general population (p < 0.05). Overall, a total of 58 (42%) participants met HADS screening criteria for anxiety and 26 (19%) participants for depression. The HCV group had a significantly higher prevalence of depression than either of the other groups (HCV = 34%, IBS = 15% and IBD = 11%, p = 0.009). In the SCL90, the three disease groups differed on 7 out of 12 subscales. On each of these subscales, the HCV group were most severely affected and differed most from the general population.ConclusionPatients with these common chronic gastrointestinal diseases have significant impairment of quality of life. Anxiety is a greater problem than depression, although patients with HCV in particular, should be regularly monitored and treated for co-morbid depression. Evaluation of specific psychological interventions targeting anxiety is warranted.

SUMMARY BackgroundSymptoms of functional gastrointestinal disorders (FGIDs) are common in patients with inflammatory bowel disease (IBD). Psychological comorbidities of anxiety and depression are also highly prevalent in IBD.

Over 200 Australian, American, and British Non-Government Organizations send aid workers overseas including missionaries. On re-entry, they may suffer psychological distress; however, there is little research about their psychosocial issues and management in the family practice setting. Research suggests loss and grief as a suitable paradigm for family practitioners dealing with psychosocial issues. The aim of this study was to explore loss and grief issues for adult Australian missionary cross-cultural aid workers during their re-entry adjustment. Mixed methods were used and this study reports the qualitative method: semi-structured interviews conducted with 15 participants. Results were analyzed using framework analysis. Themes of re-entry loss and grief were identified with sub-themes of multiple varied losses, mechanisms of loss, loss of control, common grief phenomena, disenfranchised grief, and reactivation of past grief. Theoretical and clinical implications are discussed. Findings of this study suggest that loss and grief is an appropriate paradigm for the management of these workers in the family practice setting. Further research is needed to enable appropriate care.

BackgroundA number of studies have suggested a link between the patient's psyche and the course of inflammatory bowel disease (IBD). Although pharmacotherapy with antidepressants has not been widely explored, some investigators have proposed that treating psychological co-morbidities with antidepressants may help to control disease activity. To date a systematic analysis of the available studies assessing the efficacy of antidepressants for the control of somatic symptoms in IBD patients has not been performed.MethodsWe searched electronic databases, without any language restriction. All relevant papers issued after 1990 were examined.Results12 relevant publications were identified. All of them referred to non-randomised studies. Antidepressants reported in these publications included paroxetine, bupropion, amitriptyline, phenelzine, and mirtazapine. In 10 articles, paroxetine, bupropion, and phenelzine were suggested to be effective for treating both psychological and somatic symptoms in patients suffering from IBD. Amitriptyline was found ineffective for treating somatic symptoms of IBD. Mirtazapine was not recommended for IBD patients.ConclusionAlthough most of reviewed papers suggest a beneficial effect of treatment with antidepressants in patients with IBD, due to the lack of reliable data, it is impossible to judge the efficacy of antidepressants in IBD. Properly designed trials are justified and needed based upon the available uncontrolled data.

Research into maternal protectiveness in domestic violence has focused either on women's experiences of mothering or children's experiences of growing up in domestic violence. This paper reports on a qualitative research study with both mothers and individuals who grew up in domestic violence that sought to explore perspectives on, and experiences of, maternal protectiveness in the two groups. The study used a feminist social constructionist theoretical perspective and a relational empowerment methodology, and involved interviews with nine mothers and 16 individuals who grew up in domestic violence. Thematic analysis revealed the different ways that mothers and children approached the question of so‐called ‘failure to protect’. Analysis revealed that themes of self‐blame by the mothers and mother‐blame by those who grew up in domestic violence were common, with three main thematic categories capturing the ways in which blame was constructed: (1) centring feminine traits; (2) self‐blame and guilt; and (3) the double bind of protection. The paper explores the gendered discourses about mothering and femininity that frame practices of self‐blame and mother‐blame, elaborating the double bind of protection that women face. The paper also explores the implications for practitioners who work with domestic violence in balancing the need to strengthen connections between mothers and children and, at the same time, safeguard children. Copyright © 2015 John Wiley & Sons, Ltd. Key Practitioner Messages Mothers commonly blame themselves for so-called ‘failure to protect’ their children in domestic violence. Individuals who grew up in violence often blame their mothers for ‘failure to protect’. Mother‐blame draws on a range of femininity and victim‐blaming discourses that can entangle women and children further in violence. Practitioners can encourage communication between mothers and children to repair relationships after violence.