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PSYCHOTHERAPY AND BEHAVIOUR THERAPY
45 PSYCHOTHERAPY AND BEHAVIOUR THERAPY
TABLE II-SUMMARY OF EVIDENCE FOR THE EFFICACY OF MAINTENANCE
TRICYCLIC ANTIDEPRESSIVES
S—i do
believe tnat your eaitonar
was
uncluly pessimistic about the application of scientific methods of assessment to the evaluation of psychological treatments as well as about the current evidence for the efficacy of these therapies. Besides the excellent comparative study by Sloane et al.2 which you cited there have been at least three other studies of the efficacy of psychological therapy that meet the scientific standards of controlled clinical trials (table 1).3-5 These standards include random assignment, control groups, defined inclusion and exclusion criteria, and independent assessment of outcome. All three studies have tested maintenance treatment for ambulatory depressives and all show a positive effect for the pyschological intervention, which is strongest on areas related to problems in living (i.e., interpersonal relationships and social adjustment) and which are less strong or are absent on the symptoms of depression per se. These findings for psychological treatment should be considered in the context of the results with maintenance tricyclic antidepressants in depression. All four studies (table n) show an effect for tricyclic antidepressants in preventing relapse and reducing symptoms.4-8 However, the three studies reporting data on social functioning showed either a minimal or no effect in this area. Although some recovery of social performance undoubtedly occurs as a result of the reduction of symptoms, medications themselves seem to have only a limited impact on problems in living. The similarities in findings are impressive when one considers that they were conducted independently in separate centres. Our interpretation of these findings is that for depressives there is a strong argument for combination treatment (drugs and psychotherapy). The effects of both treatments seem to be largely independent, operating on different out-
1976, i, 1225. 2. Sloane, H. B., Staples,
1. Lancet,
F. R., Cristol, A. H., Yorkston, N. J., Whipple, K. Psychotherapy versus Behaviour Therapy. Boston, 1975. 3. Weissman, M, M., Klerman, G. L., Paykel, E. S., Prusoff, B., Hanson, B. Archs gen. Psychiat. 1974, 131, 771. 4. Covi, L., Lipman, R., Derogatis, L., Smith, J. III, Pattison, J. Am. J. Psy-
Drugs seems to reduce symptoms and prevent relapse, psychotherapy is of value in enhancing social functioning. As you note, all good research raises as many questions as it answers. The results presented are for maintenance, not acute, treatments. The sample generally includes neurotic depressives and not psychotic depressives or bipolars. Despite
comes.
whereas
these limitations and the slowness with which evidence accumulates, the efficacy of these and other treatments in psychiatry need not be based on pious hope. These problems are amenable to scientific inquiry. Some progress has already been made in this direction. Depression Research Unit, Department of Psychiatry, Yale University School of Medicine, New Haven, Connecticut 06519, U.S.A.
MYRNA M. WEISSMAN
chiat.
1974, 131, 191. 5. Friedman, A. S. Archs gen. Psychiat. 1975, 32, 619. 6. Klerman, G. L., DiMascio, A., Weissman, M. M., Prusoff, B. A., Payel, E. S. Am. J. Psychiat. 1974, 131, 186. 7. Paykel, E. S., Dimascio, A., Haskell, D., Prusoff, B. A. Psychol. Med. 1975, 5, 67. 8. Mindham, R. H., Howland, C., Shepherd, M. ibid. 1973, 3, 5.
TABLE I-SUMMARY OF EVIDENCE FOR THE EFFICACY OF MAINTENANCE
PSYCHOTHERAPIES IN AMBULATORY DEPRESSIVES
ANAL DILATATION FOR HÆMORRHOIDS
SIR,-Mr Walls and Mr Ruckley’ confirm the satisfactory results which many surgeons achieve by anal dilatation for haemorrhoids. Since Lord published his method in 1968 I have done these dilatations without inserting a sponge and without prescribing a dilator. One rectal examination after a month has generally been adequate. While Lord recommends the use of a dilator for six months, I understand that Mr Ruckley and his colleagues recommend six weeks. I have long considered that if a patient can insert a dilator easily he does not need it. If he needs it because of spasm or stenosis he cannot insert it adequately. Patients often try to please surgeons by saying that they use the instrument when, in fact, if they have tried at all there has been a timorous insertion which does not pass the sphincter. Without the sponge and without the dilator we had in our first 50 cases (followed up for a year) the same satisfactory results that Walls and Ruckley report. The technique was not used in the debilitated and aged, after injection therapy, or unlike Lord, after operation for recurrence. In our hospital the cost of dilators for a year has been about 400. Some of my colleagues (rightly or wrongly) prescribe dilators after dilatation. The saving if we discard the dilator, if multiplied throughout the country, is of considerable relevance.
Broadgreen Hospital, Liverpool L14 3LB 1.
Walls, A. D. F., Ruckley, C. V. Lancet, 1976,
JOHN SHEPHERD i, 1212.
TABLE II-SUMMARY OF EVIDENCE FOR THE EFFICACY OF MAINTENANCE
TRICYCLIC ANTIDEPRESSIVES
S—i do
believe tnat your eaitonar
was
uncluly pessimistic about the application of scientific methods of assessment to the evaluation of psychological treatments as well as about the current evidence for the efficacy of these therapies. Besides the excellent comparative study by Sloane et al.2 which you cited there have been at least three other studies of the efficacy of psychological therapy that meet the scientific standards of controlled clinical trials (table 1).3-5 These standards include random assignment, control groups, defined inclusion and exclusion criteria, and independent assessment of outcome. All three studies have tested maintenance treatment for ambulatory depressives and all show a positive effect for the pyschological intervention, which is strongest on areas related to problems in living (i.e., interpersonal relationships and social adjustment) and which are less strong or are absent on the symptoms of depression per se. These findings for psychological treatment should be considered in the context of the results with maintenance tricyclic antidepressants in depression. All four studies (table n) show an effect for tricyclic antidepressants in preventing relapse and reducing symptoms.4-8 However, the three studies reporting data on social functioning showed either a minimal or no effect in this area. Although some recovery of social performance undoubtedly occurs as a result of the reduction of symptoms, medications themselves seem to have only a limited impact on problems in living. The similarities in findings are impressive when one considers that they were conducted independently in separate centres. Our interpretation of these findings is that for depressives there is a strong argument for combination treatment (drugs and psychotherapy). The effects of both treatments seem to be largely independent, operating on different out-
1976, i, 1225. 2. Sloane, H. B., Staples,
1. Lancet,
F. R., Cristol, A. H., Yorkston, N. J., Whipple, K. Psychotherapy versus Behaviour Therapy. Boston, 1975. 3. Weissman, M, M., Klerman, G. L., Paykel, E. S., Prusoff, B., Hanson, B. Archs gen. Psychiat. 1974, 131, 771. 4. Covi, L., Lipman, R., Derogatis, L., Smith, J. III, Pattison, J. Am. J. Psy-
Drugs seems to reduce symptoms and prevent relapse, psychotherapy is of value in enhancing social functioning. As you note, all good research raises as many questions as it answers. The results presented are for maintenance, not acute, treatments. The sample generally includes neurotic depressives and not psychotic depressives or bipolars. Despite
comes.
whereas
these limitations and the slowness with which evidence accumulates, the efficacy of these and other treatments in psychiatry need not be based on pious hope. These problems are amenable to scientific inquiry. Some progress has already been made in this direction. Depression Research Unit, Department of Psychiatry, Yale University School of Medicine, New Haven, Connecticut 06519, U.S.A.
MYRNA M. WEISSMAN
chiat.
1974, 131, 191. 5. Friedman, A. S. Archs gen. Psychiat. 1975, 32, 619. 6. Klerman, G. L., DiMascio, A., Weissman, M. M., Prusoff, B. A., Payel, E. S. Am. J. Psychiat. 1974, 131, 186. 7. Paykel, E. S., Dimascio, A., Haskell, D., Prusoff, B. A. Psychol. Med. 1975, 5, 67. 8. Mindham, R. H., Howland, C., Shepherd, M. ibid. 1973, 3, 5.
TABLE I-SUMMARY OF EVIDENCE FOR THE EFFICACY OF MAINTENANCE
PSYCHOTHERAPIES IN AMBULATORY DEPRESSIVES
ANAL DILATATION FOR HÆMORRHOIDS
SIR,-Mr Walls and Mr Ruckley’ confirm the satisfactory results which many surgeons achieve by anal dilatation for haemorrhoids. Since Lord published his method in 1968 I have done these dilatations without inserting a sponge and without prescribing a dilator. One rectal examination after a month has generally been adequate. While Lord recommends the use of a dilator for six months, I understand that Mr Ruckley and his colleagues recommend six weeks. I have long considered that if a patient can insert a dilator easily he does not need it. If he needs it because of spasm or stenosis he cannot insert it adequately. Patients often try to please surgeons by saying that they use the instrument when, in fact, if they have tried at all there has been a timorous insertion which does not pass the sphincter. Without the sponge and without the dilator we had in our first 50 cases (followed up for a year) the same satisfactory results that Walls and Ruckley report. The technique was not used in the debilitated and aged, after injection therapy, or unlike Lord, after operation for recurrence. In our hospital the cost of dilators for a year has been about 400. Some of my colleagues (rightly or wrongly) prescribe dilators after dilatation. The saving if we discard the dilator, if multiplied throughout the country, is of considerable relevance.
Broadgreen Hospital, Liverpool L14 3LB 1.
Walls, A. D. F., Ruckley, C. V. Lancet, 1976,
JOHN SHEPHERD i, 1212.