LA GESTIÓN POR PROCESOS

P r e s e n t S t a t e Examinat ion ( PSE)

The PSE ( Wing e t a l . , 1 9 7 4 ) i s an i n t e r v i e w t e c h n i q u e which a l l o w s p s y c h i a t r i c symptoms t o be e l i c i t e d in a s tand ard form and r e l i a b l y r a t e d . Once r a t e d t h e symptoms may be grouped i n t o syndromes g i v i n g p r o f i l e o f t h e m e n t a l s t a t e . A c l i n i c a l c l a s s i f i c a t i o n c o n s i s t e n t w i t h I CD-9 (WHO, 1978) may be d e r i v e d from symptom r a t i n g s u s i n g an o b j e c t i v e c o m p u t e r i s e d s c o r i n g s y s t e m .

Hamilton D e p r e s s i o n S c a l e

The Hamilton D e p r e s s i o n S c a l e ( H a m i l t o n , 1967) i s t h e most w i d e l y u s e d c l i n i c i a n - r a t e d s c a l e f o r e s t i m a t i n g t h e s e v e r i t y o f c l i n i c a l d e p r e s s i o n . I t con s i s t s o f 21 i t e m s c o v e r i n g mood s t a t e s , s l e e p d i s t u r b a n c e s , soma t i c s y m p t o m s , w e i g h t l o s s , r e a l i t y d i s t u r b a n c e , a g i t a t i o n and d i u r n a l v a r i a t i o n .

N e w c a s t l e D i a g n o s t i c I n d e x

T h i s s c a l e s u b d i v i d e s d e p r e s s i o n i n t o endogenous and n e u r o t i c ( C a r n e y e t a l . , 1 9 6 5 ) . There are two i t e m s on t h e d i a g n o s t i c s c a l e w h i c h s c o r e n e g a t i v e l y , " b l a m e s o t h e r s ” and " a n x i e t y ” and e i g h t p o s i t i v e i t e m s . The i t e m s and w e i g h t s used in s c a l e were d e r i v e d from t h e s t u d y o f 148 s u b j e c t s a d mi t t e d t o h o s p i t a l f o r t r e a t m e n t w i t h ECT. A l l p a t i e n t s w e r e i n t e r v i e w e d i n a s t a n d a r d way and t h e i r r e s p o n s e t o q u e s t i o n s p r e v i o u s l y found r e l e v a n t in d i f f e r e n t i a t i n g e n d o g e n o u s and n e u r o t i c d e p r e s s i o n were r e c o r d e d . C r i t e r i o n d i a g n o s e s w e r e e s t a b l i s h e d w i t h i n a few days o f a d mi s s i o n and p a t i e n t s were a l l o c a t e d e i t h e r t o a d i a g n o s i s o f d e f i n i t e endogenous o r d e f i n i t e n e u r o t i e d e p r e s s i o n . When p a t i e n t s ’ s c o r e s were p l o t t e d on t h e b a s i s

o f t h e d i a g n o s t i c i n d ex a non- unimodal d i s t r i b u t i o n was f o u n d . The c u t o f f s c o r e f o r endogenous d e p r e s s i o n i s s e t a t +6 o r g r e a t e r and f o r n e u r o t i c d e p r e s s i o n 5 o r l e s s .

P r o c e d u r e

S u b j e c t s w e r e t e s t e d a f t e r t he i n i t i a l i n t e r v i e w . In p a t i e n t s w i t h e x t r e m e r e t a r d a t i o n t h e f u l l i n t e r v i e w was d e l a y e d u n t i l some c l in i c a l improvement had taken p l a c e . Upon a r r i v a l , each s u b j e c t was i nf ormed about t h e d e t a i l s o f t h e e x p e r i m e n t . A f t e r v e r b a l c o n s e n t t o p a r t i c i p a t e , s k i n c o n d u c t a n c e e l e c t r o d e s were a p p l i e d t o t h e l e f t thumb. The t e s t i n g c o n d i t i o n s were k ep t a s s t and ar d as p o s s i b l e and r e c o r d i n g s were c a r r i e d o u t in a s o u n d - a t t e n n u a t e d room.

S k i n c o n d u c t a n c e was m e a s u r e d w h i 1 s t p a t i e n t s w e r e s e a t e d c o m f o r t a b l y i n a r e c l i n i n g c h a i r . T h i s t e s t r e p r e s e n t s an i n d i r e c t m e a s u r e o f palmar s w e at g la n d a c t i v i t y . Skin r e s i s t a n c e was measured from t h e l e f t thumb. A s e l f - a d h e s i v e foam r i n g m a i n t a i n e d a c o n s t a n t a r e a . E l e c t r o d e j e l l y (0.05M sodium c h l o r i d e ) was a p p l i e d t o t h e s k i n i n t h e r i n g . A c o n s t a n t c u r r e n t o f 14 amp/cm was p as sed t hrough t h i s e l e c t r o d e t o an e a r t h e l e c t r o d e s t r a p p e d on t h e f o r e a r m ( s e e p h o t o g r a p h s i n A pp en d i x 5 . 1 f o r e q u i p m e n t l a y o u t and e l e c t r o d e p l a c e m e n t s ) . S k i n c o n d u c t a n c e r e s p o n s e s w e r e a m p l i f i e d u s i n g an E l e c t r o n i c D e v e l o p m e n t s k i n c o n d u c t a n c e m e t e r and r e c or d ed on a D e v i c e s 10 c h a n n e l p o l y g r a p h . Skin c o n d u c t a n c e o r i e n t i n g r e s p o n s e s t o 14 o n e s e c o n d 90 d e c i b l e , 1000 Hz t o n e s g e n e r a t e d by an Amplivox a u d i o m e t e r an d p r e s e n t e d t h r o u g h l o u d s p e a k e r a t p s e u d o - r a n d o m i n t e r v a l s r a n g i n g from 15-30 s e c o n d s were m ea s u r e d . Skin co n du c ta n ce l e v e l ( SCL) was m e a s ur ed a t t he o n s e t o f each r e s p o n s e o r , i f no r e s p o n s e o c c u r r e d , a t t h e o n s e t o f t h e t o n e . S k i n c o n d u c t a n c e r e s p o n s e s w e r e d e f i n e d a s o c c u r r i n g between 1 and 5 s e c o n d s a f t e r s t i m u l u s o n s e t . S pont aneous r e s p o n s e s (SPONT) were t h o s e t h a t o cc u r r e d b e f o r e o r a t l e a s t 5 s e c o n d s a f t e r t h e t o n e . To be co unt ed as s u c h , a l l s k i n c o n d u c t a n c e r e s p o n s e s had t o have a minimum a mp li tu d e o f 0 . 0 5 m i c r o s i e m e n s . H a b i t u a t i o n (HABIT) was d e f i n e d as no measurable r e s p o n s e t o 3 s u c c e s s i v e t o n e s . Response l a t e n c i e s (LAT), r i s e t i m e s (RISET) and h a l f - r e c o v e r y t i m e s ( RECT) were a l s o c a l c u l a t e d . 9 o u t o f t h e 70 s u b j e c t s f a i l e d to have t h e i r s k i n c o n d u ct a nc e m eas ures taken b ec au s e o f equipment f a i l u r e .

RESULTS

Skin c o n d u c t a n c e in p a t i e n t s and matched normal c o n t r o l s

As T a b l e 5 . 2 i l l u s t r a t e s , r i s e t i m e , r e c o v e r y t i m e , and t h e n u m b e r o f s p o n t a n e o u s f l u c t u a t i o n s t u r n e d o u t t o d i f f e r e n t i a t e s i g n i f i c a n t l y b e t w e e n t h e t o t a l d e p r e s s i v e sample and t h e normal c o n t r o l s . B o t h t h e 1 a t e n c y an d r i s e t ime o f r e s p o n s e s w e r e s i g n i f i c a n t l y g r e a t e r f o r t h e t o t a l sample o f d e p r e s s i v e p a t i e n t s ( t = 2 . 1 9 , d f = 112, P< 0. 0 5 and t = 3 . 6 9 , d f = 1 1 2 , P<0.001 r e s p e c t i v e l y ) than normal c o n t r o l s . The r e c o v e r y ti me f o l l o w i n g a r e s p o n s e in t h e t o t a l d e p r e s s i v e s a m p l e was s i g n i f i c a n t l y l o n g e r than t h a t o f t h e normal c o n t r o l s ( t = 2 . 1 4 , d f = 1 1 2 , P< 0 . 0 5 ) . The number o f s p o n t a n e o u s f l u c t u a t i o n s in t h e t o t a l d e p r e s s i v e sample was s i g n i f i c a n t l y above t h a t o f t h e normal c o n t r o l s ( t = 2 . 3 7 , d f =112, P<0. 02) . There was no s i g n i f i c a n t d i f f e r e n c e s between t he t o t a l d e p r e s s i v e sample and t he n o r m a l c o n t r o l s on t h e number o f t r i a l s t o h a b i t u a t i o n and t h e b a s a l