In a three phase sequential treatment strategy study involving 119 depressed outpatients, a total of 31 patients (26.7%) stopped treatment prematurely due to side-effects (21/31), aggravation of symptoms (3/31), non-compliance (4/31), and non-treatment related events (3/31). At baseline, no significant differences were found on sociodemographic and psychiatric data between patients who did or did not drop out. As predictors of dropout eight domains of data concerning psychiatric history, premorbid history, symptomatology, personality, and social adjustment were used. Using a logistic linear regression analysis, only three variables were related to dropout. Patients with a history of alcohol use or poor social functioning according to axis V of the Diagnostic and Statistical Manual (DSM)-III-R had a higher chance to drop out, while patients with a sleep disturbance according to the Symptom Checklist (SCL)-90 had a smaller chance to drop out.

Medical research with incompetent patients which is expected to yield only questionable or no individual benefit (and which is often wrongly equated with non-therapeutic research) remains a difficult and controversial problem. This is reflected in the fact that such research is legally admissible in some countries such as France and England, but is questionable or prohibited in other countries, eg, Germany. Such research can only be justified ethically if the need for it is set forth according to defined criteria, and if defined protective criteria are fulfilled, particularly to ensure that the research-related instrumentalisation of the patient is held in check by observing respect for the patient's dignity, to ensure that research does not involve more than minimal risks and negligible stress for the individual participant, and that the patient's refusal to participate is accepted. A broad international consensus exists with regard to these criteria [9, 21, 26, 41]. But concepts and definitions as to what constitutes benefits and risks, as well as criteria and procedures in weighing benefits against risks, and, not least of all, the weighing of individual benefit against societal benefit, require clarification. The question must also be satisfactorily answered: who is to do the weighing? But above all, it must be ensured by professional education that this process of checks and controls is effectively carried out in day-to-day medical-scientific life.

The reconceptualisation of German traditional constructs of subaffective personality disorders (PDs) was stimulated by clinical and some empirical evidence of mild and enduring alterations of mood and drive in patients who never developed one of the full-blown mood disorders. The aim of the study was to clarify the status of historical concepts of subaffective PDs (as there are the depressive, hyperthymic, cyclothymic, and asthenic type) in relation to the modern Diagnostic and Statistical Manual (DSM)-III-R conceptions of personality disorders and the five factor theory of personality. A consecutive psychiatric sample and a normal control sample were used to investigate these relationships. By means of a non-metric multi-dimensional scaling procedure, and facet theoretical interpretation, the depressive and asthenic PDs were demonstrated to correspond highly with the global construct of PD as well as with the personality factor neuroticism which proved to be elevated in most types of PDs within the clinical sample. The hyperthymic and cyclothymic categories displayed differences to most DSM-III-R constructs of PD in the clinical but not in the control sample. The findings may explain the chronic course of some depressive or somatization disorders that are difficult to influence by pharmacotherapy and that may require special treatment strategies.

If some recent studies seem to reveal a more specific familial relationship for dysthymia in addition to a previously known familial relationship to mood disorders, and if results concerning the relationship between dysthymia and depressive personality as well as the search for possible biological and psychological correlates support the nosological validity of dysthymia, comorbidity studies raise difficult questions. Both comorbidity studies with Axis I and Axis II disorders challenge the validity of dysthymia, but as well they question the categorical model presently in use more than the validity of a definite category.

However, there are now enough data confirming some of the hypotheses implied by the nosological construct of dysthymia inside this model for this category not to be discarded. For instance, dysthymia is definitely not a personality disorder, and appears also distinct from major depression. The problem of the complex nature of the relationship between dysthymia and major depression still remains unsolved.

The European Convention of Human Rights recognises a certain number of rights and freedoms for persons within States' jurisdiction. For those confined in psychiatric hospitals, this legal protection concerns first of all the lawfulness of deprivation of liberty, which must conform to the conditions laid down by the Convention as interpreted by the case-law of the Convention organs (the Commission and Court of Human Rights). The Convention also guarantees to person deprived of their liberty further rights: the right to information, the right to appear before a court, the right to compensation and also the right to the respect of privacy and correspondence.

Panic attacks and the antipanic effect of antidepressants are claimed to distinguish panic disorder (PD) from generalised anxiety disorder. However, most studies showing neurochemical disturbances in PD overlook the non-panic state. We compared panic patients in the non-panic state with controls on biochemical, psychological and physiological measures. There were no differences on the neuroendocrine tests. Self-ratings of bodily and psychological symptoms of anxiety were significantly higher in patients and they scored worse on word recall. Patients had significantly more skin conductance fluctuations and slow wave activity in the electroencephalogram, a sign of hyperventilation which may have implications for brain activity. Discrepancies between patients' self-ratings and objective measures of pulse rate and psychomotor performance indicated that panic patients have distorted perceptions of both physical and mental functioning. Hyperventilation and cognitive distortions in the non-panic state may facilitate panic attacks and are part of the pathophysiology of PD.

The frequency of anxiety and depressive disorders was examined in 69 insulin-dependent diabetic mellitus (IDDM) outpatients and in two control group. Based on self-report measures, these disorders were similar in IDDM sample and in the control groups. In diabetic outpatients, according to DSM-III-R criteria, there was a high lifetime prevalence of not otherwise specified anxiety and depressive disorders (44% and 41.5%), of simple phobia (26.8%), social phobia (24.6%), and agoraphobia — with and without panic disorder (14.6%). Current social phobia, dysthymia and not otherwise specified depressive disorders were associated with impaired glycaemic control. Glycosylated haemoglobin was associated with compliance but psychiatric disorders were not, except for social phobia which was significantly associated with more frequent consultations and a bad compliance for dietary regimen (more snacking). Somatic complications were not associated with anxious and depressive disorders (current or lifetime) or compliance and were best explained by the duration of the illness and impaired glycaemic control.

Considerable progress has been achieved over the past 15 years in uncovering the biological basis of major psychiatric disorders. Since psychopharmacological treatment is thought tc act on the underlying biological basis of the disease, brain imaging techniques enable us to understand the mechanism of action of such compounds. One important tool used to determine patterns of brain dysfunction and how psychopharmacological agents such as antipsychotic compounds work is single-photon emission computerised tomography (SPECT). This technique allows determination of striatal D2 receptor occupancy rates, which are associated with the extrapyramidal side effects (EPS) of antipsychotic drugs. Studies have confirmed that atypical antipsychotic agents have lower occupancy rates than typical agents. No association has been found between D2 receptor occupancy rates n the striatum and antipsychotic efficacy, and it therefore appears that striatal D2 receptor occupancy rates are not necessary for the antipsychotic effect of such agents in schizophrenia. The availability of more refined radioligands will help us not only to understand the action of antipsychotics but also the pathophysiology of schizophrenia.

Clinical evidence suggests that hallucinogenic drug-induced altered states of consciousness (ASCs) and the incipient, acute stages of endogenous psychoses share many common phenomenological features. The aim of our study was to assess hallucinogen-like phenomena in endogenous psychotic patients using standardised methods. We examined 93 endogenous psychotic patients, 50 healthy controls and a small group of drug induced psychotic patients (n = 7) with two ASC self-assessment scales (questionnaire APZ = Abnormer Psychischer Zustand = Altered State of Consciousness [Dittrich et al, 1985]; and questionnaire OAV = Abbreviation of the three subscales: Oceanic Boundlessness/Angst = Dread of Ego Dissolution/Visionary Restructuralisation [Bodmer 1989]). Patients were examined shortly after remission of their last acute psychotic episode and they answered the questionnaires referring to the early phase of this episode. Differences in the questionnaire scores were significant between psychotic patients and controls. Drug induced patients had numerically higher scores than endogenous psychotic patients, however these differences were only significant for the APZ total score and the undifferentiated items of the APZ, but not for the three APZ subscale and the OAV scores. More than 50% of the endogenous psychotic patients answered 26% of the APZ-and 43% of the OAV-items with “yes”. The OAV total score and the OSE (Ozeanische Selbstentgrenzung = oceanic boundlessness) scores of both questionnaires correlated significantly with BPRS Factor 3 (thought disturbance). Our results support the hypothesis that hallucinogen-like experiences represent common phenomena during the acute stages of endogenous psychoses. Remarkably, these phenomena include subjectively pleasant experiences of the OSE dimension. In the routine clinical assessment of endogenous psychotic patients experiences of this dimension may be more easily overlooked than the negative experiences of the AIA dimension (AIA: Angst vor der Ich-Auflösung = dread of ego dissolution).

Panic disorder is a common condition. Epidemiological studies throughout the world consistently indicate that the lifetime prevalence of panic disorder (with or without agoraphobia) is between 1.5% and 3.5%. Panic disorder shows substantial comorbidity with other forms of mental illness. Major depressive disorder occurs in 50 to 65% of individuals with panic disorder and there is considerable cross-sectional and longitudinal comorbidity with recurrent brief depression and dysthymia. Phobic anxiety disorders, most notably social phobia and generalised anxiety disorder, commonly occur with panic disorder, especially in individuals with more severe agoraphobia. Approximately 35 to 50% of individuals with panic disorder in community settings also have agoraphobia. Panic disorder also shows significant comorbidity with physical illness. Compared with individuals without or with some other psychiatric diagnosis, patients with panic disorder have an increased risk of suffering from multiple medically unexplained symptoms and are associated with high use of medical services and increased mortality from both cardiovascular and cerebrovascular disease.

In a meta-analysis of the selective serotonin reuptake inhibitor fluoxetine (n = 440) and the reversible and selective monoamine oxidase-A inhibitor moclobemide (n = 437) we investigated the time course of improvement over 6 weeks for these two classes of anti-depressants. Two different methods of approach were applied: (1) repeated measurement analysis of variance in combination with regression analysis, and (2) a survival-analytical approach that allowed us to determine onset of improvement for the individual patient, to distinguish between early and late improvers, to assess the predictive value of early improvement, and to adequately process premature withdrawals. The two antidepressants of large biochemical and pharmacological differences yielded virtually identical response- and drop-out rates, and exhibited no difference with respect to the time course of improvement. Onset of improvement occurred in more than half of the patients within the first 2 weeks of treatment, and early improvement was highly predictive of later outcome. In particular, there was no indication for a delayed onset of action of antidepressants. We suggest that future studies should be standardised with respect to washout period and sufficiently dense assessments during the first 2 weeks of trial. Thus, patient samples can be subdivided reproducibly into early-, late-, partial- and non-remitters. This, in turn, may help to identify “true” drug responders, and to discover why in some patients recovery becomes “stuck”. Data already held by the pharmaceutical companies should be reanalysed in this respect.

Data on dysthymia and personality presented here are derived from the Zurich cohort study, which followed 591 subjects from the ages of 20 to 35. From childhood on, dysthymics experienced themselves as far more anxious and less self-confident than did major depressives or controls. They manifested more behavioural problems and high neuroticism and introversion scores. Dysthymics scored low in terms of quality of life, self-esteem and mastery, whereas they scored high in avoiding/denying behaviours. The hypothesis is advanced that behavioural problems, anxiety, high levels of neuroticism and personality disorders constitute risk factors for chronic depression. Evidence is presented of the existence of bipolar dysthymia.

A review of the literature showed that there is no good systematic study of a series of rigorously diagnosed “kleptomaniac” persons, other than those referred by the courts for expert opinions. This applies in particular to German-speaking and other European countries. We therefore report here on the phenomenology, demographics, psychopathology, family histories, treatment histories, behaviour therapy oriented analyses, and treatment results of 12 individuals meeting Diagnostic and Statistical Manual (DSM)-III-R criteria for kleptomania. All patients described an uncontrollable impulse to steal and a reduction in anxiety or tension during or after the act. All had at least one further psychiatric diagnosis. Although the kleptomaniac symptomatology did not seem to be part of these other disorders, the extent of stealing corresponded (positively or negatively) to other psychiatric symptoms such as depressive feelings, excessive urges to eat or migraine attacks. Microanalysis of the act of theft, as well as the preceding and following events (explored by applying behaviour therapy oriented analysis) showed intraindividually consistent, but inter-individually differing triggering factors. There was no evidence of correlation with obsessive-compulsive disorders, but some indications that kleptomania may be associated with affective disorders in terms of an “affective spectrum disorder”. According to a broader definition of “multi-impulsive-disorder” (analogous to Lacey and Evans or Fichter et al), one third of the patients might be diagnosed as “bi-impulsive disorder”. Eight of the 12 patients could be investigated at a mean follow-up time of 2 years after discharge showing favourable results. In conclusion, kleptomaniac behaviour seems to be multiconditionally caused and sustained.

The purpose of this study was to evaluate the quality of life of heroin dependent patients before and 1 year after the start of methadone maintenance treatment. Subjects were patients (n = 102) requesting treatment in a public methadone maintenance programme in Geneva (Switzerland). This was a prospective follow-up study using a validated questionnaire (SQLP). The SQLP was well accepted by patients and staff. Validity of the questionnaire was reconfirmed in this population. Compared to previously studied populations, the quality of life of heroin dependent patients before start of treatment was poor. More than half the patients were still in treatment after 1 year and their quality of life had clearly improved, in most domains. Like many of their peers in the psychiatric field, the patients had high initial expectations. Expectations decreased significantly over time. It was found that the higher were the initial expectations, the poorer was the quality of life after 1 year. The quality of life of heroin abusers requesting treatment is mediocre, and improved considerably after 1 year of comprehensive methadone maintenance treatment. Quality of life evaluation is feasible in this population and can offer an additional evaluation of quality of substance abuse treatment.

Two X-linked microsatellites, (AC)n repeats at the monoamine oxidase (MAO) A locus and (TG)n repeats at the MAO-B locus, were typed by using a PCR-based procedure in 89 nuclear families consisting of mothers, fathers and female affected offspring with schizophrenia or mothers and male affected offspring. A haplotype-based haplotype relative risk (HHRR) approach was applied to detect allelic association of these two microsatellites with schizophrenia. In the families of male patients, a significant difference in frequency distribution was found between transmitted and non-transmitted (TG)n repeats (χ2 = 15.13, df = 6, P = 0.019), and Fisher's exact test showed that allelic frequency of the transmitted (TG)24 was significantly higher than that of the non-transmitted (TG)24 (Fisher's P = 0.003). However, no significant differences in frequency distribution between mother- or father-transmitted and non-transmitted (TG)n repeats were found in the families of female patients. No significant differences in frequency distribution were found between transmitted and non-transmitted (AC)n repeats in the families of either male patients or female patients. The present study suggests that the MAO-B gene may be associated with schizophrenia, and the underlying genetic mechanism of schizophrenia may differ between male and female schizophrenic individuals.

A representative sample of teachers working at the primary or secondary grade level in both public and private schools answered an anonymous questionnaire on sociodemographic information and completed the Center for Epidemiologic Studies Rating Scale for Depression (CES-D). The teachers were classified as depressed when they scored ≥ 16 on the CES-D; 27.5% of the subjects were above this cut-off score. Logistic regression was used to calculate a multivariate model with the variables school ownership, grade level and teaching experience. Working in a public school, teaching at the primary level and longer teaching experience all increased the risk of depressive symptomatology.

Many countries have recently changed to the diagnostic system ICD-10. In Denmark a change from ICD-8 to ICD-10 was carried out in 1994. In the present study it was assessed whether the change in diagnostic system is responsible for a considerable increase in the number of registered drug abusers in the Danish mental hospitals, reported by the National Board of Health in Denmark from 1993 to 1994. Data is extracted from the Danish Psychiatric Case Register, which contains data on all psychiatric admissions in Denmark from 1970 to the present. The results show that it is not possible to follow the development of different kinds of drug abuse from ICD-8 to ICD-10. It is however, possible when setting the right conditions to make longitudinal investigations across the shift from ICD-8 and ICD-10 when estimating the total number of drug diagnoses. It is concluded that comparing data in different diagnostic systems even in different versions of the same system is demanding and that research based on such sources always must be carried out on the basis of a profound evaluation of the selection procedure, the registration principles and the diagnostic system itself. This is recommended not only in the fields of substance abuse but in all studies based on data from different diagnostic systems.