Dysthymia is estimated to afflict at least 3% of the population worldwide. Because it is a chronic disorder, its prevalence is high in psychiatric and general medical settings. The mystery of this incapacitating depressive subtype — long recognized but only recently sanctioned in the DSM-IV and ICD-10 — is that, in their habitual condition, those suffering from dysthymia lack the classical ‘objective’ or ‘major’ signs of acute clinical depression, such as profound changes in psychomotor and vegetative functions. Instead, patients consult their doctors for more fluctuating complaints consisting of gloominess, lethargy, self-doubt, malaise, and lack of joie de vivre. They typically work hard, but do not enjoy their work. If married, they are deadlocked in bitter and unhappy marriages which lead neither to reconciliation nor separation. For them, their entire existence is a burden: they are satisfied with nothing, complain of everything, and brood about the uselessness of existence. As a result, in the past they were labeled ‘existential depressives’ or ‘depressive characters’ and condemned to the couch, often on a chronic basis. Several lines of research over the past fifteen years have shed new light on the biological origins of this disorder. Sleep neurophysiologic findings have shown that many parameters of paradoxical sleep in dysthymia (such as REM percentage, REM latency, and circadian distribution of REM) are similar to those observed in major affective illness. Furthermore, family studies of dysthymia have demonstrated a significant excess of mood disorders. Indeed, dysthymia has been identified in childhood, and prospective follow-up has demonstrated major affective breakdowns including bipolar switches in up to 20%. Coupled with sleep findings, these family and follow-up data suggest that dysthymia is best considered as ‘trait depression’, a constitutional variant of major affective illness. As expected from the early onset chronic nature of the disturbance, in both clinical and epidemiological studies, the social and health burden of dysthymia has been found to be considerable and comparable to that of major medical disorders. The foregoing clinical and biological data have provided the impetus for well-designed pharmacological trials in dysthymia, and a new therapeutic optimism.

Individuals with schizophrenia who participated in a psychosocial and educative rehabilitation programme showed a 46% improvement in quality of life in the absence of any significant change in symptom severity. In contrast, there was no significant change in quality of life for individuals who continued with supportive rehabilitation. Our preliminary findings highlight the ‘quality of life’ benefits of psychosocial and educative rehabilitation for individuals with schizophrenia who are clinically stable and living in the community.

Instruments developed to measure anhedonia are reviewed and their psychometric properties and conceptual framework discussed. Most instruments were designed considering anhedonia to be a symptom either of schizophrenia or of depression. Only the Physical and Social Anhedonia Scales of Chapman et al, designed to measure a lifelong pleasure deficiency, considered to be related to schizophrenia, and, to a lesser extent, the Pleasure Scale of Fawcett et al, designed to evaluate a state dependent deficit, considered to identify a subtype of depression, have been psychometrically extensively investigated. Since we were interested in studying anhedonia in depression, we made a Dutch translation of the Fawcett-Clark Pleasure Scale and report here on the psychometric properties of this translated version. Using the Rasch model for testing the homogeneity and transferability of the scale, we demonstrated that the original scale did not fit the model. A subscale of 14 items was constructed which did.

The form, frequency and burden of sleep problems in general health care in the WHO Collaborative Study on Psychological Problems are presented in this same issue. This study was conducted in 5,438 primary care patients belonging to 15 centres in 14 countries after 25,916 patients were screened with the GHQ-12. Diagnoses according to the International Classification of Diseases (ICD-10) were obtained from the Composite International Diagnostic Interview (CIDI-PHC). The presence of difficulties falling asleep, staying asleep, waking too early or sleeping too much were assessed by the CIDI. General practitioners (GPs) gave their opinion on the existence of a psychological problem and/or a physical disease and indicated what therapeutic intervention was proposed to patients they recognized as psychological cases. The existence of sleep problems increased the recognition of patients with psychiatric disorders by their GP. No specific subtype of sleep problems influences recognition. The existence of a somatic disease had little influence on the identification of sleep problems as psychological cases. Sleep problems were not frequently expressed as a main presenting complaint. In such a case the recognition rate of patients with ICD-10 diagnosis was unchanged but a sedative treatment was offered more frequently. Overall, 85.9% of patients with sleep problems and recognized as cases were offered treatment, 53.9% drug treatment. The most frequent treatment consumed was stimulants, tonics or vitamins while the most frequently prescribed were antidepressants, hypnotic and anxiolytics with rather similar proportions. Drug consumption was substantially lower than drug prescription.

The present study was aimed at assessing the psychopathological manifestations, stress factors, evolution and social adaptation of 29 patients diagnosed with psychogenic paranoid psychosis. This syndrome is seen as an entity in itself, and is closely related to trigger factors; stability in the symptomatology of each relapse; favourable response to treatment; tendency to relapse, and recovery of the previous level of functioning.

This study investigates mood congruence effect in explicit and implicit memory tasks in 23 inpatients fulfilling DSM-III-R criteria for major depressive disorder. Performances were compared to those of 15 in- or outpatients fulfilling DSM-III-R criteria for schizophrenia, and 37 normal subjects serving as euthymics controls. All subjects were submitted to a standard cued recall test and to a word stem completion test devised to assess the effect of the initial presentation without the explicit retrieval of the words being necessary. The material used for these two tasks consisted of emotionally negative and positive words. The results show a mood congruence effect in the implicit memory task (and not in the explicit memory task) only in patients who had recovered from their major depressive episode (and not in depressed patients, schizophrenic patients, or controls). These results suggest that implicit and explicit emotional information processing differ from one another in certain respects.

Sexual and endocrine function in a geographically defined population of male patients receiving depot neuroleptic medication were studied (n = 119). It was predicted that psychosexual arousability would be reduced in this patient group, perhaps because of the endocrine effects of medication. Arousability was measured in 63 patients (53% of the population) using a validated questionnaire of sexual function for which normative data were available (Sexuality Experience Scales, SES 2). Blood levels of prolactin, testosterone and gonadotrophins were assayed. Physical sexual dysfunction was common, as was endocrine dysfunction. However, the sample's mean score on the global arousability scale was not significantly different from the normative mean. Arousability was negatively correlated with age and positively correlated with frequency of spontaneous penile erections, but not significantly correlated with endocrine variables or exposure to neuroleptic medication. These results suggest that sexual arousability in response to imagined or audio-visual erotic stimuli is surprisingly unimpaired in medicated male patients suffering from chronic mental illness.

The purpose of this study was to examine characteristics of Yugoslav patients with neurasthenia diagnosed according to the ICD-10 Diagnostic Criteria for Research (ICD-10-DCR), and to examine the ICD-10-DCR symptoms of neurasthenia and applicability of the corresponding diagnostic criteria to Yugoslav patients with this condition. Thirty-four patients with the ICD-10-DCR neurasthenia and 31 patients with mixed anxiety and depressive disorder were compared in terms of demographic variables, results of several questionnaires, symptom profiles and comorbidity with other mental disorders. Patients with neurasthenia were less educated and more often held jobs as unskilled and semiskilled workers; they had a more chronic course of illness, tended to report more symptoms, manifested more hostility, somatization and hypochondriacal tendencies and received a comorbid diagnosis of hypochondriasis more frequently. In addition to exhaustion and weakness, the most prominent features of neurasthenia were irritability, anger, nervousness, various somatic symptoms and tension. An ICD-10-DCR diagnosis of neurasthenia could not be made in slightly over one-third of patients who would have otherwise met criteria for this diagnosis because of the imposed diagnostic hierarchy, ie, due to current comorbidity with affective disorders and generalized anxiety disorder in such patients. It is concluded that the ICD-10-DCR concept of neurasthenia is generally suitable for Yugoslav patients, except for the diagnostic hierarchy requirement. The diagnostic criteria therefore require revision in order to reflect more accurately the variability in clinical presentation of neurasthenia in different countries.

This paper reviews the recent literature supporting the hypothesis that reduced neurotransmission in the mesolimbic dopamine (DA) system may sustain some of the symptoms of depressive conditions including dysthymia. Experimental evidences indicate that mesolimbic DA plays a crucial role in controlling incentive, motivation and reward. Additionally, in different models of depression, a reduced DA activity in the limbic system, reversed by chronic antidepressant treatment, is observed. Finally, different antidepressants, irrespective of their acute action on the uptake of norepinephrine or serotonin, have the common property when given chronically to potentiate behavioural responses to DA agonists. The DA hypothesis of depression offers an explanation for the antidepressive effect of drugs such as sulpiride and amisulpride given at low doses, that preferentially block DA autoreceptors and thereby increase DA output.

Dermatoglyphic patterns of fingers were studied in two hundred and fifty patients of various subtypes of schizophrenia and ninety normal control subjects. The difference between the males and female dermatoglyphic patterns in the schizophrenic and controls was found to be non significant. No difference was also found between the fingerprint patterns in patients of various subtypes of schizophrenia.

This paper describes some of the World Health Organization's (WHO.) activities related to psychosocial rehabilitation highlighting its Initiative of Support to People Disabled by Mental Illness. Critical issues related to consumer empowerment and the role consumers can play in psychosocial rehabilitation are discussed. Consensus and disagreements between medical and lay views about concepts relating to mental disorders and rehabilitation are also discussed. WHO future work in this area is indicated.

The aim of this study was to assess the effects of anxiety on attentional performance with neutral stimuli. It was set up as follows: a fourfold comparison was made of trait anxiety and state anxiety. Sixty-two undergraduate students were included in the study, and four groups of subjects were set up by a median split of the scores obtained on the Spielberger Trait and State Anxiety Inventory (STAI): high trait-high state (N = 18); high trait-low state (N = 11); low trait-low state (N = 23); low trait-high state (N = 10). A computerized battery of neuropsychological tests, the ACE battery, was administered to provide a multidimensional assessment of attention. The ACE battery comprises five tests which assess the following aspects of attention: ability to monitor a routine task; temporal preparation; visual detection; memory span; visual spatial attention and memory. High state anxious subjects displayed impairment in executive functions, manifested by a significantly higher level of motor preparation in a simple reaction time (RT) task and a speed accuracy trade-off in a divided attention task; high trait anxious subjects performed significantly better on the visual detection task. No trait × state interaction was found. It was concluded that high state anxiety is associated with psychomotor alertness and high trait anxiety with perceptual alertness. These two dimensions of psychometric anxiety seem to have effects on attention that are independent of one another and which should be analysed separately in the future.

In a previous cisternographic study of the cerebrospinal fluid (CSF) circulation in schizophrenic patients, indications for disturbed flow dynamics were found in 10 of 30 subjects. In order to replicate and investigate the clinical and pathophysiological significance of this finding, 39 schizophrenic patients and 42 healthy subjects were examined with an improved method for measurement of CSF circulation. 99mTc-DTPA was injected intrathecally and the gamma cisternograms were evaluated blindly. Correlations between cisternography findings and age, duration of disease, previous hospitalizations, positive or negative symptomatology, exposure to neuroleptics, psychiatric family history, CT findings and CSF levels of protein, tryptophan and monoamine metabolites, were calculated. Seven of the patients showed abnormalities in the cisternograms with a slow or obstructed flow of CSF over the convexities (P < 0.01) whereas none of the healthy volunteers showed abnormalities. There were no correlations between disturbed CSF circulation in the patients and the clinical and biochemical parameters, thus the significance of the deviations, similar to other biological aberrations found in schizophrenic patients, is not known. Recent developments in magnetic resonance imaging offer new possibilities to further examine CSF circulation abnormalities in schizophrenia.

The difficulty to recruit homogeneous samples of insomniacs requires alternative approaches for sleep studies. Acoustic perturbation in healthy volunteers made it possible to determine an experimental model of acute situational insomnia in order to investigate the effects of classic and novel hypnotic compounds. Unfortunately, the traditional scoring parameters of sleep are inadequate to provide reliable information for defining the neurophysiological bases of insomnia and for evaluating the efficacy of hypnotic drugs. Recent studies on the microstructure of sleep have permitted to identify a specific EEG feature, the cyclic alternating pattern (CAP), correlated with the subjective appreciation of sleep quality. Comparing placebo, zolpidem, zopiclone, lorazepam and triazolam, given at equivalent therapeutic doses in middle-aged healthy volunteer subjects under basal conditions and under acute situational insomnia, provided non-significant information when using classical sleep parameters whereas CAP rate (the percentage ratio of CAP time to non-REM sleep time) permitted to discriminate the basal nights from the perturbed nights and the drug nights from the placebo nights. These data have been confirmed in clinical studies using zolpidem versus placebo in chronic insomniacs.

The results of early therapeutic trials (1960s and 70s) in mild chronic depression (neurotic patients) are difficult to extrapolate to dysthymia. Most studies conducted in the early 1980s showed reference drugs (TCAs and MAOIs) to be poorly effective in chronic mild depression usually defined with RDC. The most recent trials using DSM-III-R criteria for dysthymic recruitment showed TCAs, new MAOIs (RIMA) and SSRI to be effective. AU these compounds have a rather similar pharmacological mechanism of action. It is therefore of both practical and theoretical interest that amisulpride, a benzamide derivative blocking D2 and D3 pre-synaptic receptors, has been found effective in the treatment of dysthymia in different placebo and reference controlled trials. This result is in line with the pharmacological data on animal ‘anhedonic models’.