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Objectives: long-term use of benzodiazepine medication results in dependence, tolerance, withdrawal symptomatology, and reduced pharmacological efficacy. In addition, long-term use of benzodiazepines can have adverse effects on cognitive, psychomotor and psychological functioning. In response to these problems prescribing guidelines clearly discourage the long-term use of benzodiazepines. The aim of the study was to examine the long-term use of benzodiazepine medication in a primary care population. The study included patients who were prescribed benzodiazepines by their general practitioners for sleep problems. Detailed information was collected regarding psychopathology, sleep difficulties and benzodiazepine dependence in this patient group with the aim of establishing whether a common psychological profile prevailed amongst those individuals who had been taking prescribed benzodiazepine medication for longer than the recommended period of time. This research study could therefore offer support to general practitioners by providing a greater psychological understanding of this client group, and mis knowledge could inform alternative treatment options. Results: Results found significant psychopathology (somatisation and phobic anxiety) in long-term benzodiazepine users. Anxiety was found to significantly predict benzodiazepine dependence and sleep difficulties. The use of long-term benzodiazepine medication did not relieve sleep difficulties. Older benzodiazepine users and daily benzodiazepine users were significantly less psychologically minded than younger users and non-daily users. Conclusion: The study concluded that long-term benzodiazepine use is ineffective in treating sleep difficulties and it would appear that anxiety is a significant feature in this cohort. Therefore, the study proposes that to address the problem of long-term benzodiazepine use in the primary care setting, psychological approaches should be employed to treat anxiety and sleep difficulties.

This thesis describes a longitudinal assessment of explanation and behaviour shift in alcohol users. It involves applying two 'process' models of addiction to the same sample of alcohol using subjects. Prochaska and DiClemente's Transtheoretical Model of Change (1979) is one of the more influential and widely used models in assessing and treating problem use of a wide range of substances. The model is based on philosophies of psychological measurement which assume literal meaning and veridical status of verbal report. The methodology employed by the Trantheoretical Model to measure an individual's 'Stage of Change' is that of forced choice questionnaire scores, which allow allocation into one of four stages of change. This method therefore assumes an individual's stage of change allocation reflects their current internal state with regard to their substance use. In contrast, the Functional Discursive model (Davies 1997) is based on philosophies of discourse and emphasises the predictive value of discourse. The model regards discourse as functional and indicative of the individual's current motivational state in relation to their substance use. Therefore the model postulates language is functional in context, and performative rather than informative. This model was developed in response to a growing dissatisfaction with many traditional methods of data collection in the field of substance use. The Functional Discursive Model is also very much a social model because the explanations surrounding the substance using behaviour occur within differing social contexts. The current study examines the efficacy and applicability of the two models which employ opposing methodological approaches. Using different treatment and non-treatment groups of alcohol users the study also assesses whether progression through the stages of either model differs according to the type of treatment intervention. In addition, two independent measures were chosen to provide additional data against which to assess anThis prompted the selection of Rosenberg's Self-esteem Inventory to measure levels of self-esteem across differing contexts (i. e. time, treatment approach and stage of alcohol use). The second independent measure included in the study was the Alcohol Use Disorders Identification Test (AUDIT), which was chosen to measure levels of problematic alcohol use across the differing contexts, to enable further comparisons to be made between the models and agencies. The general hypothesis states that the discourse based model which postulates that language is performative and context dependent will perform better across a range of contexts. The general hypothesis generates a number of more specific hypotheses which are detailed in the introduction. The following study aims to assess how the two different models perform in terms of these hypotheses. Differences and relationships between levels of self-esteem and levels of problematic alcohol use were found according to stage position in each model. For example, low self-esteem was found to be a feature of the stages (for each model) associated with problem alcohol use. Conversely, higher self-esteem was associated with non-problem stages. Use of the AUDIT confirmed patterns of alcohol use through the stages as proposed by the authors of each model. In addition, AUDIT scores closely mirrored self-esteem scores providing further confirmation that low self-esteem is associated with more problematic alcohol use. A clear relationship was also found between stage position in each model and type of treatment agency with which contact was made. Agencies supporting an abstinence-based approach to treatment were found to be treating only those individuals at the most problematic stages of each model. In contrast, agencies supporting a return to controlled drinking were found to treat individuals across a range of stages. Comparisons made between the two models suggest that while some overlap regarding the defining characteristics of individual stages was present, the Discursive Model can better accommodate a broader spectrum of substance use than is measured by the Stages of Change. Thus, the two models cannot be mapped directly onto each other. In terms of clinical application, the two models were found to be better suited to different treatment approaches. The Discursive Model appears better equipped to accommodate harm reduction and controlled drinking treatment approaches and the Stages of Change appear more pertinent to an abstinence-based approach.

Background: Depression within the older adult population is common. Previous reviews of the literature have considered the efficacy of psychological therapies for older adults. However, they have exclusively focussed on evidence provided by randomised controlled trials neglecting emergent evidence from other therapeutic modalities. Despite the efficacy of psychological and pharmacological treatments many depressed older people go without treatment. The barriers to treatment remain unclear, however the literature has previously suggested that they may fall within three factors; patients, health care providers and health care organisations. This study focussed on patient related factors. The literature has suggested that older adults not be as accurate in recognising symptoms of depression than adults of working age. In turn, lack of recognition of the presence of a mental health problem may influence older adult’s attitudes to seeking psychological help. The literature suggests a number of factors may influence treatment seeking attitudes in older people. These may include accuracy of depression recognition, cognitive fusion; engagement in valued activities although these did not appear to have previously been considered. Aims: The aims of this thesis were addressed by the systematic review of the literature and empirical research paper comprising it. Systematic review aimed, in light of a recent efficiency target issued by the The Scottish Government to update the literature relating to the efficacy of standalone psychological therapies for older adults and to consider the efficiency implications of the results. The empirical article had two overall aims. It sought to determine the predictive effect of attitudes to ageing and degree of depression on older adult’s ability to conceptualise their symptoms of psychological distress as depression. This study also sought to consider, in light of a paucity of empirical evidence to date, the relative predictive effect of attitudes to ageing, depression, recognition of depression symptoms, cognitive fusion and engagement in valued activities on the treatment seeking attitudes of a cohort of depressed older adults. Method: A systematic review of the literature was undertaken to consider the efficacy and efficiency of psychological therapies in the treatment of late life depression. An empirical cross sectional survey recruiting older adults (n = 281), aged ≥ 65 years was undertaken to examine the effects of depression, cognitive fusion, attitudes to ageing, and valued behaviour on attitudes to seeking professional psychological help. Results: In the systematic review, of the 1493 articles identified 11 were retained for review. Papers reviewed considered the effectiveness psychological interventions including: Cognitive Behavioural Therapies, Reminiscence Therapies, Acceptance and Commitment Therapy and Problem Solving Therapy. The results of the statistical analysis in the empirical work suggested that a significant proportion of ‘depressed’ older adults (n = 43) recruited to our study were not able to recognise they were depressed at the time of their participation in the study. A binomial logistic regression suggested that depression severity rather than attitudes to ageing predicted depression recognition in this sample. A hierarchical multiple regression undertaken to analyse the predictive influence of depression, depression recognition, cognitive fusion, attitudes to ageing and engagement in valued activities suggested that non of these variables significantly predicted our sample’s attitudes to seeking professional psychological help. Conclusions: Our results demonstrate that there is increasing evidence that some psychological therapies could be offered as alternatives to antidepressant medication for older people and within an efficient model of stepped care. The results of the empirical element of this project suggest that attitudes to ageing and cognitive fusion are both predictors of attitudes to treatment seeking. The results further suggest that many depressed older people don’t recognise when they are depressed suggesting a lack of mental health. These findings suggest several implications for clinical practice, psychological therapies and public health.

Background: Alongside experiencing physical symptoms with no identifiable organic cause, patients with MUS commonly experience comorbid anxiety and depression. They also have high health utilisation costs, which has implications for the health service. Interventions which target these symptoms in a cost effective way need to be developed and evaluated. Objective: To develop and evaluate a self-help mindfulness-based stress reduction (MBSR) intervention for patients with medically unexplained symptoms (MUS). Methods: A systematic review of the literature was carried out to evaluate the effectiveness of MBSR for reducing psychological distress in people with MUS. Study 1 developed and evaluated a self-help MBSR intervention in a clinical setting. Fifteen participants were recruited from eight practice, however only five completed post-intervention measures. A combination of t-tests and descriptive statistics were used to compare changes in levels of psychological distress, quality of life, symptoms and mindfulness at post-intervention. Pearson‘s correlations were used to identify relationships between improvements in mindfulness and improvements in outcomes. Study 2, exploring the reasons for the difficulties recruiting participants to Study 1, was then carried out through questionnaires to GPs. Results: Though more evidence is needed, the systematic review found MBSR to have moderate effects on psychological distress, which are largely maintained or improved at follow-up. Study 1 found symptom frequency and levels of acceptance to have improved at post-intervention. Study 2 found that the main reasons for GPs not recruiting participants was that they were busy and found it difficult to prioritise given other demands. Conclusions: Evidence to date suggests that MBSR is an effective intervention for patients with MUS. Future studies may benefit from recruiting participants from relevant organisations or using alternative methods such as database searches. No firm conclusions can be made about the self-help MBSR intervention‘s efficacy due to the study‘s limitations, however changes seen in the completer group suggest that further research would be warranted.