The community version of the MRC Needs for Care Assessment Schedule (NFCAS-C) is a new instrument designed for the psychiatric conditions seen in general populations. Its principles are based on the original Needs for Care Assessment, although that was developed for the very different population of those with long-standing mental illness (Brewin et al. 1987). The NFCAS-C is designed to reproduce, in an itemized and systematic manner, the functioning of well-organized primary care and psychiatric services. It is primarily intended for research purposes, in particular, the comparison of treatment needs and services in different populations. In this paper we describe the problems of assessing the need for psychiatric care in general populations and the rationale and development of the instrument, while in its companion we present the results of a reliability study (Lesage et al. 1995).

One hundred and nine adults were screened in the community using the abridged version of the CIDI (CIDIS). The subjects comprised DSM-III-R current cases (N = 48), lifetime cases (N = 31) and non-cases (N = 30). The interviews with the 109 subjects were conducted by one of two pairs of clinicians and videotaped. Each interviewer–pair included a psychiatrist and a clinical psychologist. They rated the community version of the Needs for Care (NFCAS-C) by consensus. The other pair of judges then viewed the video and rated the NFCAS-C independently. The agreement on overall needs was excellent (kappa = 0·75), and very good for four of the seven specific sections (from kappa = 0·61 to 0·81). One section could not be rated because of low prevalence, and agreement was less good for the remaining two sections. Agreement was good on specific interventions (medication, kappa = 0·60; specific psychotherapy, kappa = 0·55), but poor on non-specific interventions. The majority of disagreements were due to differences in clinical judgement rather than to technical errors. A new instruction manual has been produced and should help training as well as stabilizing reliability. In devising reliable and valid instruments based on clinical judgement, a balance must be achieved between enhancing reliability with more precise rules and constraining clinical judgement so tightly that validity is lost.

The association between basal cortisol, dehydroepiandrosterone (DHEA), its sulphate (DHEAS) and major depression was investigated in 8- to 16-year-olds. Eighty-two subjects with major depression, 25 non-depressed psychiatric cases and 40 community controls were systematically assessed for current mental state and hormone levels at 08.00, 12.00 and 20.00 h, assayed from salivary samples collected over a 48 h period. The average mean of the two time points was compared between the three groups. Evening cortisol hypersecretion and morning DHEA hyposecretion were significantly, and independently, associated with major depression. High evening cortisol (> 0·594 ng/ml) and low morning DHEA (< 0·200 ng/ml) identified subgroups of depressives with different types of adrenal hormone dysregulation. The association between high evening cortisol or low morning DHEA and MDD was not affected by either age or gender.

The association between high evening cortisol and low morning DHEA and the pattern of co-morbid diagnoses in 82 cases of major depressive disorder in 8- to 16-year-olds has been analysed. There was a significant association between the presence of high evening cortisol and co-morbid dysthymia. This was independent of age or sex. No positive association was found between the presence of low morning DHEA and any co-morbid diagnosis. However, co-morbid panic or phobic disorder was significantly associated with the absence of this endocrine abnormality. These findings suggest that specific endocrine disturbances may be associated with different patterns of co-morbidity during an episode of major depression in this age group.

Recent research has shown that some patients with schizophrenia have a severe impairment in the suppression of reflexive saccadic eye movements in the ANTI-saccade task. This saccadic distractibility has previously been found in patients with lesions of dorsolateral prefrontal cortex, implicating an abnormality of prefrontal cortex. The objective of the present study was to determine the contribution of these and other areas to the ANTI-saccadic abnormality in schizophrenia by functional neuroimaging. Using 99mtechnetium-HMPAO high resolution multidetector single-photon emission tomography, regional cerebral blood flow (rCBF) during performance of the ANTI-saccade eye-movement task was compared, by statistical parametric mapping, in ten male schizophrenic patients on stable antipsychotic medication who had a high distractibility error rate on the task, and eight similar patients who had normal distractibility error rates. Compared with the normal error group, the patients with high error rates showed significantly decreased rCBF bilaterally, in the anterior cingulate, insula, and in left striatum. These same patients also had increased perseverative errors on the Wisconsin Card Sort Test.

On the basis of previous findings, we used meta-analyses to consider whether births to parents with schizophrenia have an increased risk of obstetric complications. Meta-analyses were based on published studies satisfying the following selection criteria. The schizophrenic diagnosis could apply to either parent: parents with non-schizophrenic psychoses were not included: only normal controls were accepted. In all, 14 studies provided effect sizes or data from which these could be derived. Studies were identified by data searches through MEDLINE, PSYCLIT and through references of papers relating to the subject. Births to individuals with schizophrenia incur an increased risk of pregnancy and birth complications, low birthweight and poor neonatal condition. However, in each case the effect size is small (mean r = 0·155; 95% CI = 0·057). The risk is greater for mothers with schizophrenia and is not confined to mothers with onset pre-delivery or to the births of the children who become schizophrenic themselves.

African-Caribbean (N = 136) and White British (N = 192) female family planning clinic attenders were administered the Bulimic Investigatory Test, Edinburgh (BITE) and the General Health Questionnaire (GHQ-28). A proportion of the participants were subsequently interviewed. The African-Caribbeans were found to have both significantly more disordered eating attitudes and a significantly higher level of abnormal eating behaviour than the White British. Although the African-Caribbean group had a significantly higher mean Body Mass Index this did not mediate the difference in levels of eating attitudes. When compared with the White British group more African-Caribbean women reported feelings of failure, guilt, abnormality and self-consciousness concerning their eating habits. The results indicate that eating problems may be highly prevalent in this ethnic minority population and suggest that there may be differences in the nature of eating disorder psychopathology between ethnic groups.

Growth hormone (GH) responses to growth hormone releasing hormone (GHRH) of 53 in-patients meeting DSM-III-R criteria for major depressive episode with melancholia (24 non-delusional and 23 delusional depression) were compared with those of 19 healthy controls. No significant differences in basal GH were found between the control and either the non-delusional or the delusional groups. The whole group of depressed patients showed a significantly lower response than the control patients at all points of the GH response to GHRH curve as well as a lower area under curve. When the three groups (control, delusional and non-delusional depressed) were compared, it was found that only the non-delusional depressed patients had a significantly lower area under curve and lower values at +60, +90 and +120 min than the controls. The only significant difference between the two groups of depressed patients was that the delusional group showed a delayed appearance of the maximum response peak and a more prolonged response.

Groups of home and school situational hyperactive primary schoolboys identified from the community were compared with pervasive hyperactive and non-hyperactive controls on a wide range of measures. The hyperactive groups tended to persist in the same category over a half-year period. Both situational hyperactive groups had lower measured activity levels than the pervasive hyperactive group and only the latter differed from non-hyperactive controls. Home hyperactivity was characterized by poor family relationships and was not distinguishable from non-hyperactive home-antisocial controls. School hyperactive boys had specific correlates of low intelligence, motor clumsiness, poor reading and academic abilities. Pervasive hyperactive subjects differed from both situational groups in showing a higher percentage of delayed language development. While home hyperactivity has dubious identity, the distinct pattern of external correlates in school and pervasive hyperactivity speak for the need to regard these as separate entities.

Associations in 52 normal individuals were examined between plasma and cerebrospinal fluid (CSF) concentrations of tryptophan (Trp) and tyrosine, and concentrations of monoamine metabolites in the CSF, and scores on an aggression questionnaire, the Kinsey Institute Reaction List II, and the Eysenck Personality Questionnaire. There was a significantly positive correlation between CSF 5-hydroxyindoleacetic acid (5-HIAA) levels and extroverted aggression scores, and a significantly negative correlation between CSF 5-HIAA levels and introverted aggression scores. Males showed higher plasma Trp concentrations than females, and significantly positive correlations between plasma Trp concentrations and scores on extroverted aggression and the Eysenck E scale. Males, furthermore, showed a significantly negative correlation between CSF Trp levels and scores on the Eysenck P scale, and a significantly positive correlation between concentration of 3-methoxy-4-hydroxy-phenylglycol in CSF and scores on moral aggression. These results suggest that central serotonin influences aggression in normal individuals through effects on personality.

The effect of in-patient and individual orientated psychosocial intervention (IPI) and in-patient and individual and family orientated intervention (IPFI) across levels of expressed emotion (EE) on relapse was compared in a group of patients with recent onset schizophrenic disorders. Patients were randomly assigned to an individual orientated psychosocial intervention programme or to an identical psychosocial programme plus a behavioural family intervention. Seventy-six patients were studied during a 12 month out-patient treatment period after an in-patient treatment programme in which parents followed a psychoeducational programme. Overall relapse rates during the out-patient interventions were low (16%). Adding family intervention to the psychosocial intervention did not affect the relapse rate. Patients in low EE families relapsed slightly more often during the psychosocial plus family intervention. In-patient treatment with psychoeducation for parents, followed by an out-patient psychosocial intervention programme, has a favourable impact on relapse. Additional family intervention may increase stress in low EE families, thus affecting relapse in their children.

Previous studies have reported an increase in depression among recent birth cohorts. Concurrent with the increase in rates of depression, there have been increases in rates of drug and alcohol abuse and dependence. This study sought to determine if the recent increase in rates of depression could be attributed to co-morbid alcohol and drug abuse. The data derived from two studies: (1) a sample of relatives of probands with affective disorder; and (2) a community survey of the US population. The piecewise exponential statistical model was applied to evaluate the association of gender, age, period and birth cohort with rates of major depressive disorder (MDD) separately for those with, and without, diagnoses of alcohol or drug abuse.

Elevated rates of MDD occurred among those with co-morbid drug and alcohol abuse in both the family and community samples. However, there were also temporal increases in rates of MDD in those with no such co-morbidity. Specifically there were effects of age and gender for both studies; in addition, there was a period effect in the family study and a birth cohort effect in the community sample. The recent increases in depression in the US cannot be accounted for solely by concurrent increases in co-morbid drug and alcohol abuse. Temporal (period and cohort) effects on rates of depression occur in addition to the contribution of co-morbid drug and alcohol abuse or dependence.

Abnormalities in central serotonin function have been implicated in the pathogenesis of anorexia nervosa. It is difficult, however, to separate neuroendocrine abnormalities induced by weight loss and malnutrition from those related primarily to the disorder itself. To minimize these influences, this study assessed long-term weight restored anorexics. A correlation between persistent eating-related psychopathology, co-morbid illness and serotonin dysfunction was sought. Nine female weight-restored out-patients who had previously fulfilled DSM-III-R criteria for anorexia nervosa and nine healthy controls participated. Following baseline estimation, prolactin and cortisol responses to 30 mg p.o. of D-fenfluramine were measured over a 5 h period. Eating related psychopathology was assessed using the Eating Disorders Inventory and Eating Attitudes Test. Depressive and obsessional symptoms were measured using the Beck Depressive and Maudsley Obsessive–Compulsive Inventories respectively. The Tridimensional Personality Questionnaire assessed impulsivity. The weight-restored anorexic group exhibited persistent eating-related psychopathology and significant co-morbid symptomatology. There was no difference between long-term weight restored anorexics and controls in their endocrine response to D-fenfluramine. Long-term weight-recovered anorexic subjects continued to exhibit behavioural and attitudinal disturbances characteristic of anorexia nervosa. The results suggest that abnormalities in 5HT activity do not contribute significantly to trait status in anorexia nervosa.

Three hundred and twenty-six consecutively admitted patients with definite or possible functional psychotic illnesses to which no diagnostic classification had been applied were followed up after 2·5 years. In 86 cases symptomatology had been inadequate for the patients to enter the functional psychosis study, and in 75 cases this was because the symptoms were partial or transient. These patients were compared at follow-up with those who fulfilled operational criteria for schizophrenic, affective or schizoaffective psychoses. Differences between the ‘partial’ cases and those fulfilling specific diagnostic criteria were few, but the transient cases fared significantly better. Although the transient illnesses were recurrent, at follow-up at 2·5 years they appeared to have a good outcome in terms of social variables and symptomatology.

A cognitive science analysis of the interaction between psychosocial stress and the neurobiology of affective illness highlights a number of mechanisms relevant to the study of recurrence in major depressive disorder. It builds on observations previously offered by Post (1992) regarding the importance of kindling and sensitization effects in determining activation of neural structures, and proposes a model of knowledge structure activation that follows similar parameters. Vulnerability to depressive relapse/recurrence is determined by the increased risk of particular negative patterns of information processing being activated in depressed states. As is found in studies of kindling and behavioural sensitization, the likelihood of cognitive patterns being activated is dependent on the frequency of past usage, and increased reliance on these patterns of processing makes it easier for their future activation to be achieved on the basis of increasingly minimal cues. This model suggests that the processes related to relapse/recurrence and episode onset may not be isomorphic and, as such, treatments that emphasize relapse prevention strategies should take this distinction into account.

We describe the results of our follow-up magnetic resonance imaging (MRI) study of underweight patients with anorexia nervosa, using rigorous methodology to control for head position across time. All subjects first underwent an initial scan and rescan to verify that our computerized three-dimensional co-planar grid method for volume measurement was reliable and accurate, regardless of head positioning. After a period of several months, subjects had a follow-up scan to assess for changes that may have occurred following significant weight gain.

Ventricular and total brain volume measurements from the initial scans were compared with the scans from an age- and sex-matched normal control group to determine whether we could replicate previous findings of ventricular enlargement compared with controls and whether brain volume is reduced compared with controls. Anorexic subjects had significantly larger ventricles when compared with normal controls but did not differ significantly in total brain volume. Using a repeated measures analysis of variance, a priori contrasts compared the initial/rescan pair volumes with each other and the initial/rescan pair volumes with the follow-up volume. These analyses showed that ventricular and total brain volumes derived from the initial/rescan pair were nearly identical, but that at follow-up ventricular volume decreased significantly and total brain volume increased significantly after weight gain.

This study is an attempt to demonstrate confabulation in schizophrenia. Twelve patients who met DSM-III-R criteria for schizophrenia were matched for age, sex and pre-morbid IQ with 12 volunteers, 9 of whom were normal healthy subjects, with the remainder being depressed patients. To elicit confabulation, subjects were asked to recall narratives. In addition, subjects were examined on a number of neuropsychological tests. Confabulation was denned as recall of information not present in the narrative. Variable amounts of confabulation were observed in all schizophrenics, while only one control subject confabulated. The content and structure of their productions differed from previously reported forms of confabulation in that schizophrenic patients spontaneously rearranged the original narratives to produce new ideas. The amount of confabulation was found to be related to difficulties in suppressing inappropriate responses (Hayling test) and formal thought disorder, but unrelated to understanding of the gist or moral of the narratives. Tentative mechanisms for the process of confabulation are proposed, based on specific difficulties with comprehension, response monitoring and response suppression.

The dominant, contemporary paradigm for developing and refining diagnoses relies heavily on assessing reliability with kappa coefficients and virtually ignores a core component of psychometric practice: the theory of latent structures. This article describes a psychometric approach to psychiatric nosology that emphasizes the diagnostic accuracy and confusability of diagnostic categories. We apply these methods to the Diagnostic Interview for Genetic Studies (DIGS), a structured psychiatric interview designed by the NIMH Genetics Initiative for genetic studies of schizophrenia and bipolar disorder. Our results show that sensitivity and specificity were excellent for both DSM-III-R and RDC diagnoses of major depression, bipolar disorder, and schizophrenia. In contrast, diagnostic accuracy was substantially lower for subtypes of schizoaffective disorder – especially for the DSM-III-R definitions. Both the bipolar and depressed subtypes of DSM-III-R schizoaffective disorder had excellent specificity but poor sensitivity. The RDC definitions also had excellent specificity but were more sensitive than the DSM-III-R schizoaffective diagnoses. The source of low sensitivity for schizoaffective subtypes differed for the two diagnostic systems. For RDC criteria, the schizoaffective subtypes were frequently confused with one another; they were less frequently confused with other diagnoses. In contrast, the DSM-III-R subtypes were often confused with schizophrenia, but not with each other.

In a study carried out in 21 general practices in Mannheim, Germany, a stratified random sample (N = 507) of patients over the age of 65 years was drawn from the total of nearly 4000 who were medically documented. Eighty per cent of the sample were examined, using the Hierarchic Dementia Scale to test cognitive functioning and the CAMDEX criteria to assess global clinical severity. Repeat assessment after a mean interval of 27 months showed that all new cases of clinical dementia had arisen in persons with mild deficits initially and represented one-fifth of this group. The first-assessment ratings of cognitive function proved to be strongly predictive of risks for age-corrected mortality, admission to long-term care and dependency at follow-up, as well as of further progressive cognitive decline.