Objective - To investigate the form, frequency, management and outcome of common psychological disorders in primary care patients. Design - Two-stage sampling of primary care attenders followed by 3 and 12 month longitudinal assessment of mental state disability and treatment carried out using the same methods in 15 centres around the world, and coordinated by the World Health Organization. Main measures - The General Health Questionnaire, the primary care version of the Composite International Diagnostic Interview used to derive ICD-10 diagnosis, the Groningen Social Disability Schedule, and the primary care physician's assessment of the patient's current physical and psychological status along with a summary of their management of the case. Results - 25,916 patients were screened and 5,438 patients were interviewed in detail. Mental disorders among general health care attenders were common (average 24% of consecutive attenders, range 7.3%-52.5%). Disability was increased in patients with psychological illness: the more severe the psychological illness, the more severe was the disability The main presenting problem of such patients was often somatic, and only a minority presented a clearly psychological symptom. Detection varied greatly between centres, and across all centres half of the ICD-10 cases were not detected by the attending physician. Doctors in Verona displayed a particular bias towards psychological disorder. Treatment was offered to almost all patients identified as having psychological disorder by the primary care physician, though treatments showed a similar distribution regardless of diagnosis. Conclusions - The frequency and disability associated with the psychiatric disorder in general health care emphasise their importance to primary care and public health. These are patients who present to primary care, and most continue to be managed in primary care without recourse to specialist mental health services. It is important that training about the detection, diagnosis and management of common mental disorders are strengthened at medical school and in the vocational training of general practitioners.

England has set an evidence based mental health strategy which encompasses where and how people are cared for and with what aims and goals in view. It has ensured that policy is well rooted in the known epidemiology of mental disorders, that policy does not only focus on those with severe mental disorders who need specific care, but also on those with less severe disorders in primary care, in the workplace and in prisons, and also on the integration and interface of mental health services with other agencies. It has also rooted policy within a coherent framework of prevention mental health promotion, primary, secondary and tertiary prevention and prevention of mortality), and is driving that policy by measuring health outcomes as well as inputs and processes.

Objective – To consider some of the problems that may arise when the results of clinical trials are applied uncritically to everyday clinical practice. To show how an epidemiological perspective makes it easier to identify these problems. Method – A review of clinical trials to illustrate problems of: (a) covert selection bias in individual trials, (b) bias in the selection of trials included in reviews and meta-analyses. Results – Several kinds of selection bias are known to exist. In particular, trials with negative results are less likely to be published in widely read journals than are trials of similar scientific quality reporting positive results. Conclusions – There are dangers in applying the results of trials to clinical practice in an uncritical way. These dangers can be avoided by adopting and epidemiological perspective, seeking for clinical trials that are representative of the whole population of trials. The Cochrane Collaboration has been established to minimize biases in reviews and meta-analysis. The first Cochrane Centre on Schizophrenia has been established in Oxford and others are planned.

Objective – The paper discusses conceptual, methodological and clinical issues of comorbidity from the perspective of more recent epidemiological studies. Further the potential causal and pathogenic role of temporally primary disorders for the onset of secondary disorders is evaluated. Results – The available data suggest so far that comorbidity (a) is not an artefact of assessment strategies, sampling or design features, (b) is specific in different disorders, (c) is particularly frequent in anxiety and affective disorders, (d) affects systematically the course of the comorbid conditions and (0 might be related to symptom progression models. Conclusions – Furthermore, evidence is presented that specific forms of primary anxiety disorders affect the risk for secondary depressive disorders, increase the likelihood of non-remission as well as the number of subsequent depressive episodes.

Objective – To describe the trends over time of mental outpatient contacts in the Region Lazio. Design – Descriptive study. Setting – The data are based on information routinely collected by 21 mental health outpatient services during 1989–1992 period. Main outcome measures – Frequency distributions and prevalence and incidence rates. Results – Prevalence and incidence rates of psychiatric patients in treatment have been increasing in the study period. The one–year prevalence rate (per 100.000 residents) was 900 in 1989 and 1020 in 1992, with 13% increase. The incidence and point prevalence rates have increased, from 517 and 410 in 1989 to 564 and 540 in 1992 respectively. Initial diagnostic assessment was the most frequent activity performed during the first contact, accounting for about 55% of total performances. During one year, 25% of patients terminated the treatment with a dropout rate of almost 75%. In 1992, 28% of psychiatric patients terminated the treatment with a diagnosis of neurotic disorders and 69% with a diagnosis of psychotic disorders; a large number of patient terminated the treatment without any diagnosis. Conclusions – The observed increase of prevalence and incidence rates may be due to a number of factors, notably, an increase in true prevalence rates in the study area, more efficient treatment practices and an improvement in the coverage of the information system. The high rate of dropouts points to the need to evaluate the interaction between treatment settings and patient characteristics.

Objective - The analysis aims to study trends, during the period of 1983-1993, of the most relevant variables concerning equipment, staff and activity of the Lombardy Region Psychiatric Services. Setting - The study used data from all services, both hospital and community, that depend on Psychiatric Units. Data regarding Psychiatric Hospitals were not included. Design - Data were provided by the Regional Psychiatric Information System, which since 1983 has regularly collected information on equipment, staff and services supplied by the Regional Psychiatric Unit. A graphic analysis with a description of trends and the interrelation of the time series has been carried out. Main outcome measures - The analysis uses two types of variables: resources and services variables related to other community psychiatric facilities. Indexes or rates are computed to study the relations between the two sets of variables. Results - We verified a remarkable upward trend in the level of activity (both hospital and community) not entirely explained by the increase in resources. In fact, the growth of psychiatric services is linked with higher productivity and a growing demand as well. We have also seen that the growth of community activity has been stronger than that concerning hospital variables. Thus, as far as we can assess from data (not including the private sector), the use of hospitalization in psychiatric activity has decreased in the last decade. Conclusions - The analysis highlights the importance of an Information System to describe changes in service organizations and to provide data for specific studies, such as outcome studies.

Objective - Epidemiology is in focus of attention these years. Psychiatry pioneered the development of epidemiological methods and their application in research and planning. Psychiatric epidemiology has been preoccupied with the secondary health service, i.e. the hospital-based service. The aim of the present paper is to discuss which monitoring systems and which types of data will be needed in the future. Method - The discussion is based on experience and results from existing psychiatric registers, mainly the Danish Psychiatric Case Register at the Department of Psychiatric Demography in Aarhus. Results - Some countries have developed monitoring systems to routinely record data on activities in the hospital sector, which is highly beneficial to quality assurance, research, and planning. However, after the introduction of decentralized psychiatry it is necessary to acknowledge the urgent need to move the focus for the employment of epidemiology to benefit also the activities in community psychiatry and in the primary mental health care sector. Though it involves great difficulties, monitoring systems to collect valid and reliable information from these systems of care must be developed. It is also necessary to develop epidemiological methods to be employed in research and quality assurance within this field. Such research methods should be used, not only in the exploration of the aetiology, course and clinical outcome of psychiatric disorders, but also when observing, for example, the social functioning and disability of psychiatric patients, the need for care, the meeting of needs, the health economy and patient flow between the different levels of the system of treatment. This results in large demands on data security, legislation and ethics for the collection and employment of data in the epidemio-logical models. Conclusion - It is recommended to give priority to extended utilization of existing register data; establishment of secondary mental health care registers in countries without such facilities; establishment of primary mental health care registers; establishment of disability monitoring systems; establishment of systems to monitor patients' resources; extended collaboration in this work between psychiatric epidemiologists, administrators, economists, and technicians.

Objective – The analysis aims to identify the main patterns of Psychiatric Services provided by Local Health Unities in Lombardy. Setting – Data were collected by regional psychiatric information system in Lombardy in 1992 and 1993, concerning resources and activity. Design – We developed Cluster Analysis based on previously selected indicators of facilities, staff and activity. Multivariate analisys was performed in order to eliminate redundancy of information. Results – Five clusters corresponding to different patterns of psychiatric services were identified. In the first cluster services are particularly concerned with admissions (in private hospital, as well); other community activities can be considered quite dull both in composition of teams and variety of therapy. In the unities of the second cluster we pointed out low rates of community activities (mainly inside and hardly diversified) and admissions as well. The third cluster is distingueshed by an intensive community activity (both in quantity and variety) and turning to private sector for admissions, maybe because of a lack of rehabilitative facilities. Unities belonging to the fourth cluster have got many structures and a lot of staff dedicated to the hospital activity and to a intense (but little diversified) community activity. In the fifth cluster psychiatric services have got many rehabilitative facilities and community staff are well diversified; the considerable (but little diversified) community activity is carried outside. Conclusions – The community psychiatric services in Lombardy are not homogeneous and it is possible to identify five different and well definied patterns. The cluster analisys is useful to follow up the model, using information system data.