Background. General practitioners are increasingly involved in the care of patients with long-term psychiatric disorders. We have previously reported that general practitioners are less willing to treat patients with schizophrenia than those without such a diagnosis, but this may have been attributable to a reluctance to treat patients with any psychiatric or chronic illness. We, therefore, examined general practitioners' attitudes to patients with chronic psychiatric or medical illnesses.

Methods. A random sample of 260 local general practitioners were each sent one of our case vignettes which were identical apart from mention of a previous diagnosis of schizophrenia, depression, diabetes or no illness. The general practitioners were asked to indicate their level of agreement with 13 attitudinal statements based on the vignette.

Results. One hundred and sixty-six (66%) of the general practitioners responded to the case vignettes. Those responding to the vignette about the patient with schizophrenia were less happy to have that patient on their practice list and were more concerned about the risk of violence and the child's welfare. Those responding to the depression vignette were more likely to offer the patient antidepressants or counselling; and those who replied to the diabetes case were most likely to refer the patient to a hospital specialist. These differences were not attributable to the personal or practice characteristics of the general practitioners.

Conclusions. Patients with schizophrenia arouse concerns in general practitioners that are not simply due to those patients suffering from a psychiatric or chronic illness. Our results suggest that some patients with schizophrenia may find it difficult to register with a general practitioner and receive the integrated community-based health care service they require. Psychiatrists should provide education and support to general practitioners who look after patients with schizophrenia.

The effects of dopamine-antagonistic neuroleptic (NL) medication on saccadic eye movements were compared in matched groups of 40 NL-treated and 18 NL-free schizophrenic patients and in 18 NL-treated and 14 NL-free bipolar affective patients. Manipulation of the saccadic paradigm yielded data on four types of saccade: those reflexively elicited by novel stimuli (REFLEX saccades), those directed towards the remembered location of a target now extinguished (REM) or towards the location where a predictably alternating target is expected to appear (PRED), or ANTI saccades, directed away from the stimulus to the mirror image location. Extensive psychiatric, neurological and neuropsychological assessments were also carried out on all subjects. The saccades of NL-treated patients, regardless of diagnosis, were less spatially accurate than those of NL-free patients, with a greater tendency to fall short of the target when generated towards the locus of a mentally represented target. This effect was greatest with a predictably alternating target, especially during periods when target visibility was withdrawn, only a temporal cue remaining. This pattern of impairment which is also found in early stages of Parkinson's disease is likely to be due to deficiency of striatal dopamine. Its best clinical predictors were disease duration, and Webster–Parkinsonism scores. Failure to suppress reflexive saccades to the stimulus in the REM and ANTI paradigms were more closely associated with schizophrenia than with NL treatment and were best predicted by negative symptoms and Wisconsin perseverative errors, both of which are widely regarded as indicators of frontal lobe dysfunction.

Background. Although many studies have reported impairments of neurocognitive performance in patients with anorexia nervosa (AN), these have involved a wide range of assessment methods and some findings are inconsistent.

Method. Twenty-five female in-patients with a DSM-IV diagnosis of AN, identified from three units specializing in the treatment of eating disorders, volunteered for the study. Twenty-five non-clinical control subjects were recruited, matched for age, gender and estimated IQ. Subjects were assessed with a range of computer-administered neurocognitive tasks from the Cambridge Neuropsychological Test Automated Battery (CANTAB), which has been validated in many studies of neuropsychiatric disorders.

Results. The patient group showed significant but moderate impairments (i.e. less than one standard deviation below the mean performance of the control group) on tests of spatial recognition memory, a planning task and rapid visual information processing, while a subgroup of patients (n=14) showed greater degrees of impairments on at least one of these tests. The degrees of impairments did not correlate with body mass index (BMI). No impairments were observed on tests of spatial span, pattern recognition memory, spatial working memory, matching-to-sample, paired associates learning and set-shifting.

Conclusions. The findings, in relation to a mean BMI of 15·3, are compatible with, in general, subtle impairments in neurocognition in AN. However, in those patients with relatively severe degrees of impairments, these may have adverse effects on complex tasks of social and occupational functioning. Further research is needed on the nature of relevant causal mechanisms, including the effects of potentially confounding variables.

A meta-analysis of studies was carried out to compare treatment by specialist mental health professionals in the general practice setting and ‘usual GP treatment ’. Overall, treatment by specialist mental health professionals had a 10% greater success rate.

Background. Previous studies suggest that idiopathic environmental intolerance (IEI) is a variant of somatoform disorders (SFDs) or the so-called functional somatic syndromes. Little is known, however, about the stability and the psychological predictors of IEI.

Method. This prospective study examined the 1-year stability of somatic symptoms and IEI features in three diagnostic groups: 49 subjects with IEI, 43 subjects with SFD but without IEI, and 54 subjects (control group, CG) with neither IEI nor SFD. The predictive value of typical psychological predictors for somatization was tested using zero-order correlations and multiple linear regression analyses.

Results. Somatic symptoms and IEI features proved to be temporally stable over the 1-year follow-up period. The SFD and IEI groups scored significantly higher than CG on all measures of somatic symptoms and on questionnaires assessing psychological predictors for somatization. Measures of trait negative affectivity (NA), somatic symptom attribution and somatosensory amplification predicted somatic symptom severity within the IEI and SFD groups, both at baseline and 1 year later. The strongest predictors of IEI complaints in the IEI group were somatic attributions, followed by prominent cognitions of environmental threat and a tendency to focus on unpleasant bodily sensations and to consider them as pathological.

Conclusions. IEI and SFD are highly stable conditions. In both SFD and IEI, NA and the processes of symptom perception, interpretation and attribution contribute substantially to the persistence of typically somatoform symptoms and IEI complaints. Treatment of IEI and SFD should address these psychological factors and mechanisms.

Background. There is evidence that individuals with bipolar disorder exhibit neuropsychological impairments not only during episodes of depression or mania but also when they are euthymic. One of the most consistently reported cognitive problems in euthymic individuals with bipolar disorder is impairment in episodic memory. Learning and memory depend on individuals' ability to organize information during learning. A recent study by our group showed that verbal episodic memory impairments in euthymic patients with bipolar I disorder (BP-I) are mediated by difficulties in organizing verbal information appropriately during learning. The purpose of the present study was to determine whether memory impairments in euthymic individuals with BP-I extend to non-verbal memory and whether non-verbal memory impairments are mediated by difficulties in organizing non-verbal information during encoding.

Method. Study participants were 25 euthymic, remitted individuals with BP-I and 25 age, gender and education matched control participants. Participants completed the Rey-Osterrieth Complex Figure Test (RCFT), a well-established measure of non-verbal memory that enables assessment of organization during learning.

Results. Compared to control participants, BP-I participants showed impaired performance on the RCFT immediate recall. They also relied less on organizational strategies during encoding. Multiple regression modeling indicated that group differences between control and BP-I participants in long-delayed free recall did not remain statistically significant when effects of lower organization were partialled out.

Conclusions. Non-verbal memory problems in individuals with bipolar disorder, while euthymic, are mediated by poor use of non-verbal organization strategies during encoding, but do not appear to reflect deficits in retention of information.

Background. Impairments in verbal learning and memory, executive functions and attention are manifest in some euthymic patients with bipolar disorder (BPD). However, evidence is sparse on their putative role as aetiologically important genetic vulnerability markers for the disorder. This population-based study examined the cognitive functions of affected and unaffected individuals in families with BPD. The aim was to discover whether any cognitive function would indicate genetic liability to the disorder and could thus be regarded as endophenotypes of BPD.

Method. A diagnostic interview and a neuropsychological test battery were administered to 32 familial bipolar I disorder patients, 40 of their unaffected first-degree relatives and 55 controls, all representing population-based samples.

Results. Unaffected first-degree relatives showed impairment in psychomotor performance speed and slight impairment in executive function. Bipolar patients were impaired in verbal learning and memory compared with unaffected relatives and controls. They also differed from controls in tasks of executive functions. There were no difference between the groups in simple attention and working memory tasks.

Conclusions. Impaired psychomotor performance speed and executive function may represent endophenotypes of BPD, reflecting possible underlying vulnerability to the disorder. Verbal memory impairments appear to be more related to the fully developed disorder.

Evidence is presented to show that patients with Alzheimer's disease owe their memory disturbance to both an impairment in short-term memory and an additional difficulty in establishing new material in long-term storage. These findings are particularly discussed in relation to the notion that, since the pathological changes in Alzheimer's disease are particularly manifest in the hippocampal region, then this involvement of the hippocampus might explain the memory disorder. The present experiment, which is similar to one previously reported using subjects with bilateral hippocampal lesions, shows the two types of memory disorder resulting from bilateral hippocampal damage and Alzheimer's disease to be qualitatively different. Some outstanding problems with regard to obtaining a complete understanding of the nature of the amnesic phenomena in Alzheimer's disease are discussed.

Background. Suicide rates are high in later life. Risk factors include male sex and depressive illness. This study investigated the relationship between suicidal behaviour and contact with mental health services among the elderly in Western Australia.

Methods. Record linkage was used to obtain records of hospital admissions and mental health service contacts for all suicide attempts and deaths in the period 1980–95. Standardized incidence ratios were calculated for the elderly, general population and people with mental health service contacts. Cox regression was used to evaluated potential risk factors for elderly people who were in contact with mental health services.

Results. People over 60 years of age accounted for 15% of suicides and 4·6% of attempted suicides. Suicide rates were 3·3 times higher in males and 4·4 times higher in females when compared to the general population of elderly people. For attempted suicide, the rate was 5·8 times higher in males and 6·6 times higher in females with prior contact with mental health services. Highest risk of suicide was found in patients with diagnoses of affective psychoses (RR = 3·7), adjustment reaction (RR = 3·2) or depressive disorder (RR = 2·8). The diagnosis of cancer was associated with decreased risk of suicide (RR = 3·6) and attempted suicide (RR = 1·9).

Conclusions. Suicide rates are high among the elderly in Western Australia. Suicide is significantly associated with the diagnosis of mood disorder. Suicide attempts are less common, and are associated most strongly with mood and personality disorders. The decreased risk of self-harm behaviour among patients with cancer warrants further investigation.

A consecutive series of school age children (7 to 16 years) with emotional disorders (N = 100) were compared with a series of community controls (N = 100) matched for age, sex and social class for the quality of their friendships. A semi-structured interview was developed to measure the quality of friendship for this purpose. Significantly more (48%) children with emotional disorder were likely to be rated as experiencing moderate to poor friendships in the 12 months prior to the onset of symptoms than were controls (16%) in the 12 months prior to interview. Prepubertal children with moderate to poor friendship patterns were classified as either predominantly anxious or depressed. Postpubertal children with moderate to poor friendships patterns were, in contrast, predominantly anxious. These findings suggest that puberty denotes a point of change for the impact of friendship deficits on the psychopathology of emotional disorder. There were no sex differences in the clinical classification of children with moderate or poor friendship patterns.

Background. An increasing number of individuals with diverse health complaints are currently seeking help in the field of environmental medicine. Multiple chemical sensitivity (MCS) or idiopathic environmental intolerances (IEI) is defined as an acquired disorder with multiple recurrent symptoms associated with environmental chemicals in low concentrations that are well tolerated by the majority of people. Their symptoms are not explained by any known psychiatric or somatic disorder.

Method. Within a 2-year period we examined 264 of 267 consecutive patients prospectively presenting to a university based out-patient department for environmental medicine. Patients underwent routine medical examination, toxicological analysis and the structured clinical interview for DSM-IV psychiatric disorders (SCID).

Results. Seventy-five per cent of the patients met DSM-IV criteria for at least one psychiatric disorder and 35% of all patients suffered from somatoform disorders. Other frequent diagnoses were affective and anxiety disorders, and dependence or substance abuse. In 39% a psychiatric disorder, in 23% a somatic condition and in 19% a combination of the two were considered to provide sufficient explanation of the symptoms. Toxic chemicals were regarded as the most probable cause in only five cases. The suspected diagnosis of MCS/IEI could not be sustained in the vast majority of cases.

Conclusion. This investigation confirms previous findings that psychiatric morbidity is high in patients presenting to specialized centres for environmental medicine. Somatoform disorders are the leading diagnostic category, and there is reason to believe that certain ‘environmental’ or MCS patients form a special subgroup of somatoform disorders. In most cases, symptoms can be explained by well-defined psychiatric and medical conditions other than MCS, which need specific treatment. Further studies should focus on provocation testing in order to find positive criteria for MCS and on therapeutic approaches that consider psychiatric aspects.

Background. Depression is usually the predominant affective state in bipolar disorder. There are few studies, with discrepant views, examining the extent of cognitive impairment in patients with bipolar depression. To our knowledge, there are no previous studies examining decision-making ability or whether there is an affective attentional bias in bipolar depression.

Method. We ascertained 24 depressed bipolar I patients from acute psychiatric hospital wards and out-patient clinics and 26 age- and IQ-matched healthy controls. Using computerized tests we evaluated their performance on ‘neutral’ (non-emotional) cognitive tasks (i.e. memory, attention and executive function) and on novel tasks of emotional cognition (i.e. the decision-making task and the affective go/no-go task).

Results. Accuracy measures were significantly impaired on tests of visual and spatial recognition and attentional set-shifting in bipolar depression compared with age- and IQ-matched controls. The quality of decision-making was also significantly impaired in the patients. A mood-congruent attentional bias for ‘sad’ targets was not evident on the affective go/no-go task.

Conclusions. We found widespread evidence of significant cognitive impairment and impaired quality of decision-making in symptomatically severe depressed bipolar patients. This cognitive impairment may contribute to difficulties with daily living, decision-making and the ability to engage and comply with psychological and drug treatments.

Numerous studies have estimated the frequency of bulimia nervosa among high school girls and college women, but population-based trends in incidence in a community have not been reported.

In this study we determined the incidence of bulimia nervosa by identifying persons residing in the community of Rochester, Minnesota, who had the disorder initially diagnosed during the 11-year period from 1980 to 1990. Using our comprehensive population-based data resource (the Rochester Epidemiology Project), we identified cases by screening 777 medical records with diagnoses of bulimia; feeding disturbance; rumination syndrome; adverse effects of cathartics, emetics, or diuretics; polyphagia; sialosis; or vomiting.

We identified 103 Rochester residents (100 female and 3 male) who fulfilled DSM-III-R diagnostic criteria for bulimia nervosa during the 11-year study period. Mean ± S.D. age for females at the time of diagnosis was 23·0 ± 6·1 years (range, 14·4 to 40·2 years). Yearly incidence in females rose sharply from 7·4 per 100000 population in 1980 to 49·7 in 1983, and then remained relatively constant around 30 per 100000 population. The annual age-adjusted incidence rates were 26·5 per 100000 population for females and 0·8 per 100000 population for males. The overall age-and sex-adjusted annual incidence was 13·5 per 100000 population.

Bulimia nervosa is a common disorder in adolescent girls and young women from 15 to 24 years of age. Histories of alcohol or drug abuse, depression, or anorexia nervosa were higher than expected in the general population.