Terminal illness does not necessarily prevent a person from settling his or her affairs or from getting enjoyment as before through being with family and friends.
human erythropoietin is being used include the anaemia of prematurity, myelodysplastic syndromes, and anaemia associated with HIV infection. It has also been used to increase the number of units of blood harvested for autologous transfusion.2' These results are still preliminary. Molecular biologists have provided a dazzling new array of recombinant growth factors of which recombinant human erythropoietin is one. The unlimited availability (apart from cost considerations) should permit the treatment of patients with anaemia in new and exciting ways either with growth factor monotherapy or with suitable combinations of recombinant growth factors. HENRY HAMBLEY Locum Consultant Haematologist
GHULAM J MUFTI Senior Lecturer Department of Haematological Medicine, King's College Hospital, London SE5 9RS I Carnot 1, D)eflandre C. Stir l'actisite hemopoictiquc des ditffercnts organcs au cours de la regeneration de sang. Comptes Rendus des Seances de L'Academie des Sciences, Paris 1906;143: 432-5. 2 Reissmani KR. Studies on the mechanism of erythropoietic stimulation in parahiotic rats duiring hy poxia. Blood 1950;5:372-80. 3 Erslev AJ. Htimoral regulation of red cell production. Blood 1953;8:349-57. 4 Jacobson 1,0, Goldwasser E, Fried W, Plzak LK. 'I'he role of the kidney in erythropoiesis. Nature
1957;179:633-4. 5 Schuster SJ, Wilson JH, Ersles' AJ, Caro J. Physiologic regulationi and tissue localisation of renal erythropoictin messeinger RNA. Blood 1987;70:316-8. 6 Mivake T, Kung CKH, Goldwasscr E. Purification of human erythropoietin. j Biol sChem 1977;252:5558-64. 7 Powell JS, Berkner KL, Lebo RV, Adamson JW. Hutman crythropoietin gene: high level expression in stably transf'ected mammalian cells anid chromosomal localisation. Proc Natl Acad Sci CSA 1986;83:6465-9.
8 Lai P-H, Everett R, Wang F-F, Arakawa T, Goldwasscr E. Structuiral characterisation of huiman Biol Chterm 1986;261 :3116-2 1. crythropoictin. R 9 Spivak JL, Hogans BB. 'I'he in vivo mnctabolism of rccombinant htuman erythropoietin in the rat. Bllod 1989;73:90-9. 10 Koury ST, Bondurant MC, Koury MIJ. Localisation of'ervthropoictin synthesizing cells in murine kidneys by in situ hybridization. Blood 1988;71:524-7. 11 Fried W. The liver as source of extrarenal erythropoietin. Blood 1972;40:671-7. 12 Kuirtz A, Eckardt K-U, 'I'annahill L, Bauer C. Regulation of erythropoietin production. Contrib Nephrol 1988;66:1-16. 13 Eckardt K-U, Kurtz A, Bauer C. Regulation of erythropoietin production is related to proximal tubular ftunction. Am] Phtvsiol 1989;256:942-7. 14 Iscove NN. The role of ervthropoietin in regulation of poptilation size and cell cycling of early and late erythroid precursors in mouse honie marrow. Cell Tissue Kinet 1977;10:323-34. 15 Umemura T, Papayannopoulou T, Stomatovannopoulos G. The mechanism of expansion of late erythroid progenitors during ervthroid regeneration: target cells and effects of erythropoietin and interletikin-3. Blood 1989;73:1993-8. 16 Broudy VC, Lin N, Egrie J, et al. Identification of the receptor for erythropoietin on human anld murine ervthroleukemia cells and modulation by phorbol ester and dimethyl sulphoxide. ProcANtlAcadSci USA 1988;85:6513-7. 17 ILandschtilz KT, Noyes AN, Rogers 0, Boyer SH. Erythropoietin receptors on murine erythroid colotty-forming units: nattural history. Blood 1989;73:1476-86. 18 McCaffrey P'J, Fraser JK, Lin F-K, Berridge MV. Subunit strtucture of the erythropoietin receptor. ] Biol Chem 1989;264: 10507-12. 19 Eckardt K-U, Bauer C. Erythropoietin in health and disease. Eur3' Clin Invest 1989;19:117-27. 20 McGonigle RJS, Husserl F, Wallin JD, Fisher JX1W. Hemodialysis and continuous ambulatory peritoneal dialysis effects on erythropoiesis in renal failure. Kidney Int 1984;25:430-6. 21 Caro J, Brown S, Miller 0, Murray T, Ersley AJ. Ervthropoietin levels in tiremic nephric and anephric patients. ] Lab Clin Med 1979;93:449-58. 22 Hochberg MC, Arnold CM, Hogans BB, Spivak JL. Serum immunoreactive ervthropoietin in rheumatoid arthritis: impaired response to anemia. Arthritis Rheum 1988;31:1318-2 1. 23 Birgegard G, Hallgren R, Caro J. Serum erythropoietin in rheumatoid arthritis and other inflammatory arthritides: relationship to anaemia and the effects of anti-inflammatory treattnent. Br] Htaematol 1987;65:479-83. 24 Winearls CG, Oliver DO, Pippard Ml, Reid C, Downing MR, Cotes PM. Effect of human erythropoietin derived from recombinant DNA on the anaemia of patients maintained by chronic haemodialysis. Lancet 1986;ii: 1 175-7. 25 Eschbach JW, Egrie JC, Downing MR, Browne JK, Adamson JW. Correction of the anemia of end-stage renal disease with recombinant human erythropoietin. N Engl3' Med 1987;316:73-8. 26 Adamson JW. The promise of recombinant erythropoietin. Semin Hematol 1989;26(suppl 2):5-8. 27 Means RT, Olsen NJ, Krantz SB, et al. Treatment of the anemia of rheumatoid arthritis with recombinant human erythropoietin: clinical and in vitro studies. Arthn'tis Rheum 1989;32: 638-42. 28 (Goodnough LT, Rudnick S, Price TH, et al. Increased preoperative collection of autologous blood with recombinant hutnan erythropoietin therapy. N Englj Med 1989;321:1163-8.
Patients' reactions to illness Cognitive factors determine responses and are amenable to treatment People differ widely in their emotional responses to physical illness. Persistent emotional disturbance is more common in those with a history of psychiatric illness' or with inadequate social supports.2 Whether or not a patient becomes depressed or anxious is only weakly associated, if at all, with the severity of the illness or of the physical symptoms.' 3-6 What seems to matter most are the sufferer's cognitions: attitudes to and thoughts and beliefs about the illness. Emotional disturbance is particularly associated with dysfunctional cognitions-that is, beliefs that do not serve an adaptive purpose and are given exaggerated emphasis or may even be false. For example, a man who believed that his myocardial infarct had resulted from his straining to pass urine was anxious and unable to return to his previous life because he felt unable to close the door whenever he was using the lavatory. Terminal illness does not necessarily prevent a person from settling his or her affairs or from getting enjoyment as before through being with family and friends. Yet some patients who are terminally ill develop the dysfunctional belief that all happiness will henceforth totally elude them. If this belief results in their withdrawing from social intercourse it becomes self fulfilling. Emotional disturbance is not inevitably linked with dysfunctional cognitions, however, and similarly not all abnormal beliefs are dysfunctional. For example, a man who was undergoing haemodialysis long term had worked out a plan to commit suicide if his circumstances oLc-unie intolerable. Despite continuing suicidal thoughts he coped adequately with his illness. He became severely depressed when he discovered that he could not bring himself to end his life. Undue 622
optimism may help some patients with cancer,7 and excessive denial may also be adaptive in some circumstances."' Such clinical observations are well supported by evidence from research. For example, the degree of pain and disability in arthritis are more closely associated with cognitive variables than with the duration or severity of the illness."1'S Patients with low back pain who are also depressed have more distorted perceptions of the impact of their back pain than their non-depressed peers. 16 Patients with a variety of illnesses who believe that their symptoms might become uncontrollable are more likely to be depressed or anxious, regardless of their physical state.2''718 In a recent study of outpatients in a dermatology clinic Wessely and Lewis found that psychiatric morbidity was independent of the site, extent, or duration of the skin disease but related to attitudes towards appearance and to the behavioural impact of the skin disorder. '9 Dysfunctional or not, cognitions are usually unspoken, beyond normal awareness, and taken as axiomatic. Dysfunctional beliefs about illness commonly reflect lay or idiosyncratic theories of disease, which may be difficult for doctors to recognise or expect and so need to be elicited actively. Learning to identify and to modify dysfunctional cognitions are core elements of cognitive therapy.20 This is well established as being effective for depression2' and is being applied to a growing range of problems.2226 Its efficacy has been shown in managing chronic pain27 28 and in reducing the psychiatric morbidity associated with cancer293' as well as the disability caused by asthma32 and chronic obstructive airways disease.33 BMJ VOLUME 300
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Some types of cognitive therapy-such as those used in managing personality disorders and in conditions traditionally seen as suitable for psychoanalytic treatment-are time consuming and require considerable experience and skill.34 By contrast, in cases of anxiety, depression, and physical illness cognitive therapy is characteristically briefand focused. It not only addresses current cognitions but also teaches the patient how to deal with these more successfully in the future. Thus, cognitive therapy should have a prophylactic effect, and there is already some evidence that it does.3537 And if cognitive techniques may be successfully acquired by patients they must also be accessible to general practitioners, physicians, and other specialists. They are described in treatment manuals,3839 and they offer considerable scope for improving communication between doctors and their patients.26 Cognitive therapy initially developed empirically from clinical observation. One of the main strengths of the cognitive model, however, is its support and enhancement by experimental research.4142 This convergence of clinical and experimental data is shown well in a recently published handbook of cognitive therapy.26 Reliable data of this kind allow therapists to determine the particular cognitive factors associated with defined types of illness and so to develop specific interventions. Several studies that are testing such interventions are in progress. Their success, and the ease with which they can be applied by clinicians who are not specialists in cognitive therapy, will define more clearly the role of cognitive interventions in physical illness. Senior Lecturer in Psychiatry, Charing Cross and Westminster Medical School, West Middlesex University Hospital,
TOM SENSKY
Isleworth, Middlesex TW7 6AF 1 Feldman E, Mayou R, Hawton K, Ardern M, Smith EBO. Psychiatric disorder in medical inpatients. QJ,Med 1987;241:405-12. 2 Broadhead WE, Kaplan BH, James SA, ea al. The epidemiologic evidence for a relationship between social support and health. AmJ7 Epidemiol 1983;117:521-37. 3 Wise rN, Mann LS, Puscheck E, Dove H, Kiernan K. Factors affecting anxiety and depression in psychiatric consultation patients. Inil Psychiatry Med 1985-6;15:177-84. 4 Rosenberg S1, IPeterson RA, Hayes JR, Hatcher J, Headen S. Depression in medical in-patients. Br,7 Med Psychol 1988;61:245-54. 5 Hawley DJ, Wolfe F. Anxiety and depression in patients with rheumatoid arthritis: a prospective study of 400 patients. J Rheumatol 1988;15:932-41. 6 Ell K, Nishimoto R, Morvay T, Mantell J, Hamovitch M. A longitudinal analysis of psychological adaptation among survivors of cancer. Cancer 1989;63:406-13.
7 Taylor SE. Adjustment to threatening events: a theory of cognitive adaptation. Am Psvchol 1983;38: 1161-73. 8 Greer S, Morris T, Pettingale KW. I'sychological concomitants of breast cancer-effect on outcome. Lancei 1979;ii:785-7. 9 Levenson JL, Kay R, Monteferrante J, Herman MV. Denial predicts favourable outcome in unstable angina pectoris. Psychosom Med 1984;46:25-31. 10 Levine J, Warrenburg S, Kerns R, etal. The role of denial in recovery from coronary heart disease. Pvchosom Med 1987;49:109-17. 11 Flor H, Furk DC. Chronic back pain anid rheumatoid arthritis: predicting pain and disability from cognitive variables.]7 Behav Med 1988;1 1:251-65. 12 McFarlane AC, Brooks PM. An analysis of the relationship between psychological morbidity and disease activity in rheumatoid arthritis.] Rheumatol 1988;15:928-31. 13 Smith TW, Peck JR, Milano RA, Ward JR. Cognitive distortion in rheumatoid arthritis: relation to depression and disability.]7 Consult Clin Psychol 1988;56:412-6. 14 Revenson TA, Felton BJ. Disability and coping as predictors of psychological adjustment to rheumatoid arthritis. ] Consult Clin Psychol 1989;57:344-8. 15 Keefe FJ, Brown GK, Wallston KA, Caldwell DS. Coping with rheumatoid arthritis pain: catastrophizing as a maladaptive strategy. Pain 1989;37:51-6. 16 Lefebvre MF. Cognitive distortion and cognitive errors in depressed psychiatric and low back pain patients. ] Consult Clin Psychol 1981;49:517-25. 17 Devins GM, Binik YMA, Gorman P, et al. Perceived self-efficacy, outcome expectancies, and negative mood states in end-stage renal disease. 7 Abnorm Psvchol 1982;91:241-4. 18 Affleck G, Tennen H, Pfeiffer C, Fifield J. Appraisals of control and predictability in adapting to a chronic illness.]J Pers Soc Psychol 1987;53:273-9. 19 Wessely SC, Lewis GH. The classification of psychiatric morbidity in a dermatology clinic. Br] Psychiatry 1989 (in press). 20 Beck AT. Cognitive therapy and the emotional disorders. New York: Meridian, 1976. 21 Dobson KS. A meta-analysis of the efficacy of cognitive therapy for depression. ] Consult Clin Psychol 1989;57:414-9. 22 Turk DC, Meichenbaum D, Genest M. Pain and behavioral medicine: a cognitive-behavioural perspective. New York: Guilford, 1983. 23 Hawton K, Salkovskis PM, Kirk J, Clark DM. Cognitive behaviour therapy for psychiatric problems. Oxford: Oxford University Press, 1989. 24 Moorey S, Greer S. Psychological therapy for patients with cancer: a ness approach. Oxford: Heinemann, 1989. 25 Rush AJ. Cognitive approaches to adherence. In: Frances AJ, Hales RE, eds. American Psychiatric Press review of psychiatry, vol 7. Washington: American Psychiatric Press, 1988:627-42. 26 Freeman A, Simon KM, Beutler LE, Arkowitz H, eds. Comprehensive handbook ofcognitive therapy. New York: Plenum, 1989. 27 Turner JA, Clancy S. Strategies for coping with chronic low back pain: relationship to pain and disability. Pain 1986;24:355-64. 28 Philips HC. The effects of behavioural treatment on chronic pain. Behav Res Ther 1987;25:365-77. 29 Worden JW, Weisman AD. Preventive psychosocial intervention with newly diagnosed cancer patients. Gen Hosp Psychiatry 1984;6:243-9. 30 Tarrier N, Maguire P. Treatment of psychological distress following mastectomy: an initial report. Behav Res Ther 1984;22:81-4. 31 Fishman B, Loscalzo M. Cognitive-behavioural interventions in management of cancer pain: principles and applications. Med Clin North Am 1987;71:271-87. 32 Maes S, Schlosser M. Changing health behaviour outcomes in asthmatic patients: a pilot study. Soc Sci Med 1988;26:359-64. 33 Atkins CJ, Kaplan RM, Timms RM, Reinsch S, Lofback K. Behavioural exercise programmes in the management of chronic obstructive pulmonary disease. J Consult Clin Psychol 1984;52: 591-603. 34 Beck AT, Freeman A, eds. Cognitive therapy ofpersonality disorders. New York: Guilford (in press). 35 Kovacs M, Rush AJ, Beck AT, et al. Depressed outpatients treated with cognitive therapy or pharmacotherapy. Arch Gen Psychiatry 1981;38:33-9. 36 Blackburn IM, Eunson KM, Bishop S. A two year naturalistic follow up of depressed patients treated with cognitive therapy, pharmacotherapy and a combination of both. ] Affective Disord
1986;10:67-75. 37 Simons AD, Murphy GE, Levine JL, etal. Cognitive therapy and pharmacotherapy for depression: sustained improvement over one year. Arch Gen Psychiatry 1986;43:43-8. 38 Beck AT, Rush AJ, Shaw BF, Emery G. Cognitive therapy ofdepression. New York: Guilford, 1979. 39 Beck AT, Emery G. Anxiety disorders and phobias: a cognitive perspective. New York: Basic Books, 1985. 40 Williams JMG. Cognitive psychology and emotional disorders. Chichester: Wiley, 1988. 41 Brewin CR. Cognitive foundations of clinical psychology. Hove: Lawrence Erlbaum, 1988. 42 Fisher S, Reason J, eds. Handbook of life stress, cognition and health. Chichester: Wiley, 1988.
Juniors' hours of work eightysomething is too long The BMA and the government both agree that junior hospital doctors should work no longer than 72 hours a week. Yet the most recent figures show them contracted for a weekly average of 82 hours.' Given the rare agreement between doctors and the government over such a fundamental condition of service why does such a wide gap persist? Concentrating on the size of the gap obscures the progress that has been made regarding juniors' hours in recent years. One in one rotas have been outlawed and attempts made to eliminate, firstly, one in two rotas and then rotas more onerous than one in three. Together, these initiatives have brought down the average number of hours worked each week from the upper 80s a decade ago. But government circulars and intermittently functioning district working parties are clearly not enough: a survey by regional health authorities BMJ
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showed that last September 22% of doctors had more onerous rotas than one in three. And despite the exhortations from the Department of Health going back to 1982 many one in two rotas remain. So what can be done? Three separate solutions could each reduce contracted hours at a stroke. Firstly, the government could turn its long term aim of a 72 hour a week maximum into legislation, and the National Health Service and Community Care Bill, currently before parliament, would seem the ideal vehicle for this. Legislation on shorter hours might have been expected to follow a statement in the government's Self-Governing Hospitals: An Initial Guide that self governing hospitals would be expected "to comply with the Government policy relating to the number of houirs for which junior doctors may be employed."2 In its current state, however, the 623
