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Social Support, Anxiety and Depression After Chemotherapy for Ovarian Cancer: A Prospective Study

Posted on: Saturday, 20 November 2004, 03:00 CST

Objectives. We aimed to describe the levels of anxiety and depression in patients during the 3 month period following the end of chemotherapy treatment and to identify factors that predict psychological morbidity.

Method. We performed a prospective study in women with ovarian cancer to determine the changes in psychological status in the 3 months following completion of chemotherapy. Sixty-three consecutive patients were assessed at the completion of chemotherapy (Time 1) and 57 at 3 months follow-up (Time 2). Relevant disease and patient characteristics were recorded and patients were assessed at Time 1 for anxiety, depression and their perception of emotional support, an index of their psychosocial environment. Anxiety and depression were re-assessed at Time 2.

Results. The results indicate significant initial psychological morbidity, with clinical caseness for anxiety (38%) and depression (33%) being common. Follow-up at Time 2 shows that patients undergo a significant reduction in cases (19%) and symptoms of depression but an increase in cases of anxiety (47%). The principal factors associated with symptoms of anxiety at Time 2 were poor perceived social support, increased intrusive thoughts and, to a lesser extent, younger age. Medical parameters, such as the stage of disease, response of the cancer to treatment, Ca125 (a tumour glycoprotein) and Karnofsky Performance status (a measure of how well the patients is) were not associated with worse psychological outcome.

Conclusion. These data show for the first time that social support and intrusive thoughts, rather than physical parameters, are the principal determinants of psychological morbidity in patients with ovarian cancer.

Introduction

Ovarian cancer is responsible for the deaths of approximately 25,000 women in the US and 5000 women in the UK each year. Most women are diagnosed when the disease is at a late-stage with in excess of 70% having disease outside the pelvis (Greenlee, Murray, Holden, & Wingo, 2000). Standard chemotherapy consists of intravenous paclitaxel in combination with a platinum compound, commonly carboplatin. Typically, treatment is given at 5-weekly intervals for six cycles (Adams et al., 1998) The side effects of chemotherapy are well documented and include nausea and vomiting, alopecia, peripheral neuropathy and myclosuppression (Huizing et al., 1997; Markman et al., 2001; Trimble et al., 1993).

The prevalence of psychological disorders, especially symptoms of anxiety and depression, in cancer patients is high (Derogatis et al., 1983). A recent review concluded that the prevalence reported in different studies was influenced by patient selection, assessment measures and whether symptoms or disorders were identified (Sellick & Crooks, 1999) Prevalence rates for diagnosed depression vary between 6 and 15%, but considerably more patients, between 23 and 60%, reported symptoms of depression, which caused considerable distress, but were insufficient to meet recognized diagnostic criteria (Sellick & Crooks, 1999). Anxiety and concerns about the future and recurrence also abound (Cameron, Leventhal, & Love, 1998; Cella, Mahon, & Donovan, 1990; Easterling & Leventhal, 1989) Although the prevalence of psychological disorders in cancer patients is higher than in the general population these often go unrecognized and untreated, and may persist for up to 6 years following treatment of the cancer (Cull, Stewart, & Altman, 1995). The consequences may be serious if the diagnosis and treatment of anxiety and depression are ignored. Cancer patients suffering psychological disorders experience deterioration in quality of life, are less compliant with medical care, have longer hospital stays and have higher mortality rates (Newport & Nemeroff, 1998). Evidence for the association of demographic factors such as age (Derogatis et al., 1983; Espie, Freelander, Campsie, Souter, & Robertson, 1989; Goodwin, Hunt, Key, & Samet, 1987; Payne, 1992) and disease variables (Berard, Boermeester, & Viljoen, 1998; Bukberg, Penman, & Holland, 1984; DeHaes, van Knippenberg, & Neijt, 1990; Derogatis et al., 1983; Ell, Nishimoto, Morvay, Mantell, & Hamovitch, 1989; Newport & Nemeroff, 1998; Veit & Ware, 1983) with psychological disorders has been equivocal.

Ovarian cancer patients represent a relatively homogenous disease group who follow a similar treatment regimen involving investigation, surgery and chemotherapy. Women with ovarian cancer report a signincant deterioration in quality of life up to 1 year after treatment, irrespective of treatment response (Guidozzi, 1993) However, the impact of ovarian cancer on psychosocial functioning is a relatively neglected area of research. By the time a woman has finished chemotherapy, she has experienced a series of ongoing traumatic life events (a diagnosis of cancer, surgery and chemotherapy) all of which involve frequent medical consultation and examination, and she may not have had time to adjust to the consequences. The remission period, following the completion of chemotherapy, is often associated with increased anxiety and distress following decreased medical surveillance and the absence of safety signals to indicate that the cancer will not return (Hurt, McQuellon, & Barrett, 1994). There has been anecdotal clinical evidence that some women, despite a successful treatment response, experience distress at the end of treatment (Mayfield, 1999) This phenomenon has been explained by a loss of the 'safety net' of treatment and can be associated with increased anxiety symptoms (Ward, Viergutz, Tormey, Demuth, & Paulen, 1992). As ovarian cancer typically presents with no overt symptoms, patients in remission have no warning or safety signal to indicate the cancer will or will not return. The period when treatment ends has been described as the 'neutral' time, associated with reduced medical surveillance, leading to increased anxiety, uncertainty and fears of recurrence. These factors would seem to leave some women vulnerable to psychological distress, however, there has been limited research in this area.

The importance of social support to good mental health outcomes is well established (Rhodes & Lakey, 1999). As well as the positive effect of good social support, the detrimental effect of negative interactions with significant others in the social environment has also become apparent in psychiatric and other conditions (Butzlaff & Hooley, 1998; Wearden, Tarder, Barrowclough, Zastowney, & Rahill, 2000). Such negative interpersonal environments have been assessed, both through interviews with the significant others (Tarrier, Somerfield, & Pilgrim, 1999) and the perception of the patient (Hooley & Teasdale, 1989), and have been shown to be associated with poor psychological outcome. For example, negative interpersonal interactions or their perceptions have been found to be associated with the onset of psychological disorder (Holeva, Tarrier, & Wells, 2001; McCarthy, Tarrier, & Gregg, 2002), their relapse (Hooley & Teasdale, 1989; Steketee & Chambless, 2001) and poor response to treatment (Tarrier et al., 1999). Although many cancer patients derive considerable support from their significant others, unhelpful responses to cancer patients from those close to them are well documented and have been shown to have significantly adverse effects on their well-being (Manne, Taylor, Dougherty, & Kemeny, 1997; Pistrang & Barker, 1995). In an investigation of 129 heterogeneous cancer patients it was found that medical and clinical factors were not associated with later psychological distress, although age was, with older patients exhibiting less distress. However, high levels of intrusive thoughts about cancer and perceived spouse criticism were related to psychological distress 3 months later (Manne, 1999). Cancer patients may well have significant worries, concerns and anxieties about their disease and its consequences. A supportive social and interpersonal environment may help patients to process these anxieties, whereas an unreceptive significant other, or one who is perceived to be so, may inhibit cognitive processing of the traumatic experience of cancer resulting in persistent emotional disorder (Manne, 1999). There is some indication from the literature that in a sample of breast cancer patients the nature of the relationship with the patient, whether spouse, relative or friend affects the quality of social support (Pistrang & Barker, 1992, 1995).

The aims of this study were to describe the levels of anxiety and depression in patients with ovarian cancer and the changes in psychological health status during the 3-month period following the end of chemotherapy treatment when the women may be at increased risk of psychological morbidity due to the termination of intense medical scrutiny. Furthermore, we wished to identify factors that predict psychological morbidity in ovarian cancer patients. Specifically we tested the following hypotheses: (i) that anxiety and depression would increase after the termination of chemotherapy; (ii) age, but not cancer disease variables, would be associated with anxiety and depression; and (iii) that high levels of intrusive thoughts and perceptions of poor social support at the end of chemotherapy would be associated with high levels of anxiety and depr\ession at follow-up.

Method

Design

This was a prospective naturalistic study of consecutive clinic attenders to assess and predict psychological morbidity in ovarian cancer patients completing chemotherapy. Patients were assessed at the end of chemotherapy (Time 1) and again at 3-month follow-up (Time 2), a period when medical attention was greatly reduced.

Participants

Study participants were recruited from consecutive attenders at the outpatient department of the Christie Hospital, Manchester, UK, over an 11-month period from May 2000 to March 2001. All the women had been diagnosed with epithelial ovarian cancer (EOC) and were fully informed with respect to stage of disease. The patients were approached between cycles 5 and 6 of a platinum-based chemotherapy regimen. Individuals who were not fluent in English or who were unable to provide informed consent were excluded from the study, as were those with high levels of suicidal ideation or organic brain disorders. All women attending the clinic who had just completed a course of chemotherapy were asked to participate in the study. The study was approved by South Manchester Local Research Ethics Committee and all the patients gave informed consent.

Measures

A structured interview schedule was used to obtain information about patient characteristics and a medical history. Questions were included to assess the patient's history of cancer, past psychiatric history, the occurrence of recent life events, family history of cancer and co-existing physical health problems, which were considered as potential confounding factors. A subjective rating of current physical health was obtained by asking patients to rate their physical health on a 7-point scale (0 = extremely ill to 6 = well, healthy, strong) (Matthews et al., 1999).

Psychological morbidity

Anxiety and depression

The Hospital Anxiety and Depression Scale (HADS) was chosen as the main outcome measure of psychological distress (Zigmond & Snaith, 1983). It was administered to all participants in the study at both time points. The HADS is a brief 14-item questionnaire designed to detect anxiety and depression in medically ill patients. Unlike other scales, the HADS omits somatic symptoms of anxiety and depression and is of particular use in detecting psychological distress in patients with chronic illness. It has been used widely to detect psychological morbidity in cancer patients (Herrmann, 1997). Items are scored numerically and provide a score for anxiety and depression, with higher scores indicating increased symptoms. Identification of clinical caseness for anxiety and depression is made by a score of 8 or above on each subscale.

Intrusive thoughts

The Impact of Events Scale (IES; Horowitz, Wilner, & Alvarez, 1979; Zilberg, Weiss, & Horowitz, 1982) was used to provide a measure of current subjective distress in terms of frequency and severity of intrusive thoughts about cancer. It is a widely used self-report measure of specific responses to trauma. The scale contains 15 items, with two subscales namely intrusions and avoidance. The IES has been utilized with cancer patients (Cordova et al., 1995). A modification was made to the scale so that 'cancer' was specified when asking about the content of intrusive thoughts. In this study, the intrusions subscale was used to assess intrusive thoughts about cancer.

Social and emotional support

A visual analogue scale of 10cm was drawn to measure the perceived quality of social and emotional support experienced by the patient from their significant other. The anchor points indicated on the scale were 0 (very poof) to 100 (very good) with each centimetre being regarded as 10%. This is a briefer, single-item version of the Social Support Inventory (Holeva et al., 2001) for which there was good internal consistency (Cronbach's α = .83) and acceptable test-retest reliability over 4 weeks (r = .55) and had been used in a study investigating the effect of social support on the onset of seasonal affective disorders (McCarthy et al., 2002). Self-report measures of the quality of the emotional relationship have frequently been used in the literature and have been shown to have good reliability, concurrent and predictive validity, and are economical and easy to use (Chambless & Steketee, 1999; Hooley & Teasdale, 1989; Van Humbeeck, Van Audenhove, De Hert, Peters, & Storms, 2002). This instrument also has the advantage of being quick and easy to complete thus minimizing the burden to the respondent which can endanger recruitment and retention.

Medical/clinical measures

The following measures of disease and function were recorded: (i) the FIGO stage of the disease, which is a measure of how far the disease has spread. Stage I disease is limited to the ovaries, Stage II disease is in the pelvis, Stage III disease is in the abdomen and Stage IV disease involves distant organs; (ii) the Karnofsky performance (KP) status (Karnofsky & Burchenal, 1949) at the time of presentation at Christie Hospital which is a measure of how well the patient is. This ranges between 100 when the patient is perfectly well through to 0 when the patient is dead. The scale increases in values of 10% according to the physical well-being of the patient; (iii) the concentration of Cal25 at the end of treatment (normal or abnormal: upper limit of normal was 28IU/ml). The Cal25 is a tumour glycoprotein found in the patient's serum. Changes in this protein parallel responses to chemotherapy in the tumour and are used as a guide to the efficacy of therapy; (iv) the best treatment response to chemotherapy (WHO, 1979). A partial response is defined as at least a 50% reduction in the cross-sectional area of tumour masses, whereas a complete response refers to a complete regression in tumour. Progressive disease refers to a 30% increase in tumour cross- sectional area, whereas stable disease is any that does not fulfil the aforementioned criteria.

Procedure

All the patients were treated by a single medical team. Patients received carboplatin-based chemotherapy in which carboplatin was administered at an AUC (Area Under the Curve) of 5 (combination) or 6 (single agent) (Calvert et al., 1989), every 3 weeks for six cycles. This is a standard drug, dose and regimen for this condition. Computed tomography (CT) scans were performed at the start and end of treatment and the CaI 25 was measured before each cycle and at the end of treatment. The follow-up regimen planned that patients would be seen every 3 months until 2 years after initial chemotherapy and then every 6 months until 5 years from chemotherapy. This research programme was conducted in the first 3 months after women had completed chemotherapy.

At Time 1, the completion of chemotherapy, patients were interviewed and questionnaires were administered in a private room in the outpatient clinic. It was anticipated that the patients might be apprehensive prior to the medical consultation (Lampic et al., 1994), which might temporarily inflate levels of psychological distress, therefore, all patients were interviewed following their appointment with the medical consultant. The second interview was carried out 3 months following the completion of chemotherapy. For those unable to attend the second interview the option of returning the questionnaires by post was offered.

Statistical analysis

Data were analysed using the Statistical Package for the Social Sciences (SPSS) Version 10.0. Descriptive statistics were used to describe the sample characteristics. Distribution-free statistical tests were used to compare measures that were categorical or where measures significantly departed from normal, otherwise parametric statistics were used for group comparisons. When correlations were carried out significance was set at p < .01 to avoid chance findings due to multiple testing. All tests were two-tailed. Stepwise multiple regression analyses were used to investigate associations between variables at the end of chemotherapy at Time 1 (independent or predictor variables), and the symptoms of anxiety and depression at 3-month follow-up, Time 2, (dependent variables). The predictor variables were selected on an a priori basis as potentially influential in determining psychological morbidity. A two-phase approach to model building was adopted with patient characteristics and cancer disease variables being included in the initial analyses to ascertain which of these variables were significantly associated with the dependant variables. A second analysis was then carried out including those variables that were significant in the first analysis and the psychological variables of intrusive thoughts and perceived quality of emotional support.

Results

Sample

Eighty-seven patients were eligible for recruitment. Fourteen patients were not informed about the study during the study period for logistic reasons (a holiday period during which recruitment was discontinued rather than having partial recruitment). Of the 73 patients approached by medical and nursing staff about the research project 63 (86%) agreed to participate. Ten patients (14%) who were informed declined to take part. Reasons given included 'not wanting to talk about it' and a lack of time due to transport arrangements.

Sixty-three patients completed all the initial questionnaires at Time 1. Fifty-seven (90%) of these patients also completed the questionnaires at Time 2 (3-month follow-up) which represented a very good response rate. Thirty-five patients (61%) completed the follow-up questionnaires at the clinic. Twenty-two follow-up questionnaires (39%) were mailed and returned by post. There were no significant differences between patients who received clinic or postal follow-ups.

Of the significant others, 43 (68%) were a spouse or partner and 20 (32%) were another relative or friend. In the latter group there were nine daughters, three sons, one mother, five sisters, one aunt \and one close friend. Of the 63 significant others, 46 were male and 17 female.

Patient characteristics

Table 1 lists the characteristics and descriptive statistics of the women who participated in the study. There were no significant differences between those who did and did not complete follow-up.

Table 1. Patient characteristics and scores on assessment measures

Anxiety and Depression: HADS scores

At Time 1, 24 patients (38%) scored in the clinical range on the anxiety scale and 21 (33%) scored in the clinical range on the depression scale. There was considerable co-morbidity with 17/63 (27%) being cases for both anxiety and depression. At Time 2, 27 patients (47%) scored in the clinical range on the anxiety scale with 11 patients (19%) scoring in the clinical range on the depression scale (Fig. 1). This represented a significant increase in anxiety cases (McNemar's test, p = .001) and reduction in depression cases (McNemar's test, p < .004). Over time there was a significant reduction in depression scores (t = (56)2.87, p = .006).

The gender of the significant other and their relationship with the patient

Comparisons between the relationship of the significant other with the patient (spouse/partner vs. other) and gender of the significant other were made on the HADS scores and with the perceived quality of social support. There were no significant results except that the spouse/partner had higher HAD anxiety scores at Time 2 (means: spouse/partner = 7.97, SD = 4.77; Other = 5.37, SD = 4.18, t(55) = 2.02, p = .048).

Predictors of psychological outcome

To examine factors associated with anxiety and depression at Time 2, stepwise multiple regressions were performed with the anxiety and depression scores on the HADS at Time 2 as the dependent variable. This was to investigate which factors were significantly and independently associated with anxiety and depression at follow-up. Continuous measures of anxiety and depression were used in this analysis as some patients experienced symptoms but were not cases and continuous dependent variables would increase the power of the test to detect associations with this sample size. The first phase included patient and disease characteristics. The second phase retained those found to be significant and further added the psychological variables.

Anxiety

Anxiety at Time 1, previous cancer diagnosis, other physical health problems, subjective physical health rating, history of mental health problems, Ca125, KP status, stage of disease, response to treatment and time since diagnosis of ovarian cancer were entered as independent variables. Anxiety at Time 1 (B = .632, SE = .092, t = 6.85, p < .001) and age (B = -.109, SE = .048, t = -2.285, p = .027) were significantly and independently associated with anxiety at time two (F(2, 47) = 34.9, p < .001) with these two variables explaining 58% of the variance in the dependent variable; high levels of initial anxiety and younger age being associated with higher subsequent levels of anxiety. The other predictor variables were not significant and were excluded from the model.

Figure 1. Changes in the percentage of cases of anxiety and depression from the end of chemotherapy to 3-month follow-up.

A second regression was performed with anxiety at Time 2 as the dependent variable with anxiety at Time 1, perceived emotional support, nature of the significant others relationship with the patient (spouse/partner or other) and age entered as independent variables. The nature of the significant others relationship with the patient was not significant and excluded. All three other independent variables significantly entered the model (F(3, 55) = 36.18, p < .001; anxiety at Time 1: B = .582, SE = .083, t = 7.02, p < .001; perceived emotional support: B = -6.53, SE = .022, t = - 2.95, p = .005; and age: B = -8.14, SE = .037, t = -2.23, p = .03), explaining 64.5% of the outcome variance. High levels of initial anxiety, poor emotional support and younger age were associated with higher subsequent levels of anxiety. This analysis was repeated with IES - intrusions scale score at Time 1 entered instead of anxiety at Time 1. This model was also significant (F(3, 55) = 19.01, p < .001) explaining 48% of the variance.

Depression

Similar analyses were performed with depression at Time 2 as the dependent variable. In the first analyses only depression at Time 1 (B = .543, SE = .115, t = 4.73, p < .001) significantly predicted depression at Time 2 (F(1, 48) = 22.38, p < .001) predicting 30.4% of the variance. A second analysis was performed with perceived emotional support being included with depression at Time 1 as independent variables. The model was significant (F(2, 56) = 19.38, p < .001) with both depression at Time 1 (B = .521, SE =.102, Beta = .53, t = 5.09, p < .001) and perceived emotional support (B = -6.4, SE = .023, Beta = -0.287, t = -2.76, p = .008) contributing to the final model and explaining 38.8% of the variance. High levels of depression and poorer emotional support were associated with later depression.

Discussion

We found significant prevalence of cases of anxiety (38%) and depression (33%) in this cohort of ovarian cancer patients at the end of chemotherapy. However, there were evident changes in morbidity over the follow-up period with a significant increase in anxiety cases (47%; p = .001) and a significant decrease in cases of depression (19%; p < .004). These changes were associated with a perceived lack of social support and increased intrusive thoughts. To our knowledge, the differential direction of anxiety and depression has not previously been reported. Our initial hypothesis was that psychological morbidity would increase after chemotherapy was confirmed in that there was an increase in the number of clinical cases of anxiety. However, the number of clinical cases of depression decreased during this period. This suggests that the termination of chemotherapy and cessation of medical consultations increases vulnerability to anxiety although not to depression. Furthermore, these results emphasize the importance of investigating anxiety and depression separately.

It would seem probable that anxiety is increased in some women because in the absence of external safety signals, such as medical consultation and scrutiny, they search for internal signs, that they are remaining well or that the cancer is recurring, through self- directed attention to physical sensations and internal states. However, as the cancer is largely asymptomatic there are few internal signs and symptoms that they can actually monitor or attend to that will accurately inform them of the status of their disease. By monitoring internal sensations they are more likely to attend to and accentuate somatic sensations resulting in increased anxiety. Such a process of attention to somatic sensations, misinterpretation and accentuation is well established in anxiety disorders (Clark, 1986).

Investigation of factors that later predict psychological morbidity indicate that those related to the disease, such as disease stage, response to treatment, KP status, and Ca125 (a serum tumour protein indicative of the tumour's response to treatment), past history or family history of cancer were not associated with psychological morbidity. This result is consistent with findings in the literature that physical disease factors are not associated with psychological morbidity (Berard et al., 1998; DeHaes et al., 1990; Ell et al., 1989) However, a younger age is associated with anxiety, possibly because the threat of aggressive illness and its consequences is greater.

We found that poor quality of perceived emotional support was significantly associated with later anxiety and depression. This is a finding which has consistently been reported in the psychiatric literature (Butzlaff & Hooley, 1998; Holeva et al., 2001, Hooley & Teasdale, 1989; McCarthy et al., 2002; Tarrier et al., 1999; Wearden et al., 2000) and also in the cancer literature (Brady & Helgeson, 1999; Manne, 1999; Manne et al., 1997; Matthews et al., 1999; Pistrang & Barker, 1995). We speculate that this represents a measure of the emotional quality of the key interpersonal relationship, which may have inhibited the processing of concerns about the disease and hence maintained or exacerbated anxiety. The process may be iterative, with those who are most distressed behaving in a way that discourages support from their relatives and their perception of this lack of support increases their anxiety.

We did not confine the sample to women who had a spouse or partner and included those whose significant other was another relative or in one case a close friend. To have done so would have excluded 32% of the sample and potentially endangered generalization. However, there was little indication from our results that the relationship or gender of the significant other significantly affected the level of distress experienced by the woman. The exception to this was that women with a spouse or partner had significantly higher levels of anxiety at the follow-up assessment, although this association was present it did not independently predict the level of anxiety in a multiple regression. Pistrag and Barker (1995) found in breast cancer patients, that the quality of the helping relationship with the partner was associated with psychological well-being. Even though most women did have a good relationship with another person this did not compensate for a problematic relationship with the partner. They also found that women with partners were more distressed than those without, however, these women were also younger and when age was controlled for the association between being with a partner and distress disappeared. This finding was similar to the results reported here. In a heterogeneous group of married cancer patients Baider, Koch, Esacson, and De-Nour, (1998) found that the patient's level o\f distress was predicted by the level of intrusions and the spouse's level of psychological distress but the patient's sense of family cohesion had no protective influence. It may be that the patient's level of distress is influenced by their partner's level of distress. Pistrang and Barker (1992) reported that many women in their breast cancer sample wanted to protect their partner from worrying and that they felt he could not cope with their thoughts and fellings.

The ability to successfully mobilize positive social and emotional support is an important coping strategy to regulate emotional arousal and promote rational thinking and facilitate the processing of emotional reactions to trauma (Beck, Rush, Shaw, & Emery, 1979; Tarrier, 1996) in this case of suffering serious life- threatening illness. Psychological morbidity is an important problem in cancer patients and the results from this study suggest potential cognitive-behavioural interventions which may be designed to alleviate threat, mobilize social support and prevent the increase in anxiety cases.

Acknowledgements

The results presented here -were submitted by the first author for the degree of Doctor in Clinical Psychology, in the Faculty of Medicine, University of Manchester, 2001. We are grateful to all the patients who took part, to Dr Julie Morris of the Department of Medical Statistics, Wythenshawe Hospital for statistical advice and Sr. Lynn Broughton and Anne-Marie Lydon for nursing support. There was no conflict of interest or commercial involvement in this study.

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Received 15 May 2003; revised version received 16 February 2004

Jane Hipkins1, Melissa Whitworth2, Nicholas Tarrier1* and Gordon Jayson2

1 School of Psychiatry and Behavioural Science, Wythenshawe Hospital, University of Manchester, UK

2 Cancer Research UK Department of Medical Oncology, Christie Hospital NHS Trust, Manchester, UK

* Correspondence should be addressed to Professor Nicholas Tamer, School of Psychiatry and Behavioural Sciences, University of Manchester, Education and Research Building (2nd Floor), Wythenshawe Hospital, Manchester M23 9LT, UK (e-mail: nicholas.tarrier@man.ac.uk).

Copyright British Psychological Society Nov 2004

Source: British Journal of Health Psychology

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