The age of onset in bipolar affective disorder was determined in 200 hospitalized patients. The mean age of their first affective syndrome was 28·3 years, and the mean age of first hospitalization was 30·8 years. However, the median age for first affective syndrome was 23 years (26 years for first hospitalization), and the most common age of onset was 15–19 years. Those patients with an early onset, especially if they were first hospitalized for mania, were most likely to have received a diagnosis of schizophrenia.

Background. Studies measuring the effects of psychotherapy on brain function are under-represented relative to analogous studies of medications, possibly reflecting historical biases. However, psychological constructs relevant to several modalities of psychotherapy have demonstrable neurobiological correlates, as indicated by functional neuroimaging studies in healthy subjects. This review examines initial attempts to measure directly the effects of psychotherapy on brain function in patients with depression or anxiety disorders.

Method. Fourteen published, peer-reviewed functional neuroimaging investigations of psychotherapy were identified through a MEDLINE search and critically reviewed. Studies were compared for consistency of findings both within specific diagnostic categories, and between specific modalities of psychotherapy. Results were also compared to predicted neural models of psychotherapeutic interventions.

Results. Behavioral therapy for anxiety disorders was consistently associated with attenuation of brain-imaging abnormalities in regions linked to the pathophysiology of anxiety, and with activation in regions related to positive reappraisal of anxiogenic stimuli. In studies of major depressive disorder, cognitive behavioral therapy and interpersonal therapy were associated with markedly similar changes in cortical–subcortical circuitry, but in unexpected directions. For any given psychiatric disorder, there was only partial overlap between the brain-imaging changes associated with pharmacotherapy and those associated with psychotherapy.

Conclusions. Despite methodological limitations, initial neuroimaging studies have revealed convergent and mechanistically sensible effects of psychotherapy on brain function across a range of psychiatric disorders. Further research in this area may take advantage of emerging neuroimaging techniques to explore a broader range of psychotherapies, with the ultimate goal of improving clinical decision-making and treatment.

Background. Neuroticism has been shown to increase the risk of depression whereas extraversion is associated with a reduction of risk. These personality traits play a central role in aetiological theories of affective disorder but their role in schizophrenia is unclear. In this study, the risk for schizophrenia associated with neuroticism and extraversion was examined and quantified.

Methods. Neuroticism and extraversion rated at the age of 16 years were examined in relation to adult schizophrenia in a national birth cohort of 5362 individuals.

Results. Neuroticism increased the risk of later schizophrenia independent of the level of affective symptoms in adult life (odds ratio over three levels: 1·93, 95% CI 1·09–3·43), whereas extraversion reduced the risk (OR: 0·44, 95% CI 0·23–0·84).

Conclusions. Depression and schizophrenia may share personality risk-increasing and risk-reducing factors. Coping styles associated with particular personality traits may determine whether isolated symptoms progress to full-blown illness.

Depression is well recognized to be rooted in the down-regulation of positive affect systems. This paper reviews some of the social and non-social theories that seek to explain the potential adaptive advantages of being able to tone down positive affect, and how dysfunctions in such affect control can occur in some contexts. Common to most evolutionary theories of depression is the view that loss of control over aversive events and/or major resources/rewards exert downward pressure on positive affect. Social theories, however, suggest that it is loss of control over the social environment that is particularly depressogenic. Two evolutionary theories (the attachment-loss, and the defeat-loss theories) are briefly reviewed and their interaction considered. It is suggested that phenotypes for toning down positive affect, in the face of loss of control, may become more severe in the context of socially hostile, unsupportive and/or excessively competitive environments. The paper briefly considers how human competencies for self-evaluation in relation to others, rumination, self-criticism, and modern social contexts can accentuate dysfunctional expressions of affect regulation.

Background. Although major depression is a common condition across the age range, there is some evidence from clinical studies that it may be more persistent and disabling in older adults. This study examined the demographic, socio-economic and clinical factors associated with major depression and with persistence of depressive symptoms at 2- and 4-year follow-ups in a large population sample of middle-aged and older adults.

Method. In a sample of 9747 participants aged over 50 in the 1996 wave of the US Health and Retirement Study, the authors assessed the 12-month prevalence of major depression using the Composite International Diagnostic Interview – Short Form (CIDI-SF). Significant depressive symptoms at the time of 1996, 1998 and 2000 interviews were assessed using a short form of the Center for Epidemiological Studies Depression Scale (CES-D).

Results. The 12-month prevalence of CIDI-SF major depression was 6·6%. With age, prevalence declined, but the likelihood of significant depressive symptoms at follow-ups increased. Both prevalence and persistence of significant depressive symptoms at follow-ups were associated with socio-economic disadvantage and physical illness. Persistence of depressive symptoms at follow-ups was also associated with symptoms of anhedonia, feelings of worthlessness, and thoughts of death at baseline.

Conclusions. Sociodemographic, physical health and a specific profile of depressive symptoms are associated with a poorer course of major depression in the middle-aged and older adults. These indicators may identify a subgroup of patients in need of more careful follow-up and intensive treatment.

Data on the history of cannabis use and a spot urine test for cannabinoids were obtained for 137 schizophrenics in treatment. Subjects who were using cannabis during the 6-month observation period presented with a significantly higher degree of delusional and hallucinatory activity than those who did not. Moreover, the group using cannabis made a higher average number of visits to the hospital during the same period. The status of cannabis use appeared to contribute to such variance more than did other relevant factors (age, stage of the illness, amount of medication prescribed, occasional use of other psychoactive substances).

The Eating Attitudes Test (EAT) and General Health Questionnaire (GHQ) have been validated in an unselected population of 15-year-old South London schoolgirls. Scores on the questionnaires were compared with the results of standard interview. The EAT was found to be an efficient screening instrument for abnormal eating attitudes and behaviour, whereas the GHQ was less satisfactory in its ability to screen for psychiatric morbidity in this age group than in adults. At the optimal cutting points, 6·9% of this population gave a positive response to the EAT and 19·3% gave a positive response to the GHQ. There was a statistically significant positive correlation between the two sets of scores

Background. Sociological studies have shown that poor social integration confers suicide risk. It is not known whether poor integration amplifies risk after adjusting statistically for the effects of mental disorders and employment status.

Method. A case-control design was used to compare 86 suicides and 86 living controls 50 years of age and older, matched on age, gender, race, and county of residence. Structured interviews were conducted with proxy respondents for suicides and controls. Social integration was defined in reference to two broad levels of analysis: family (e.g. sibship status, childrearing status) and social/community (e.g. social interaction, religious participation, community involvement).

Results. Bivariate analyses showed that suicides were less likely to be married, have children, or live with family. They were less likely to engage in religious practice or community activities and they had lower levels of social interaction. A trimmed logistic regression model showed that marital status, social interaction and religious involvement were all associated with suicide even after statistical adjusting for the effects of affective disorder and employment status. Adding substance abuse to the model eliminated the effects of religious involvement.

Conclusions. The association between family and social/community indicators of poor social integration and suicide is robust and largely independent of the presence of mental disorders. Findings could be used to enhance screening instruments and identify problem behaviors, such as low levels of social interaction, which could be targeted for intervention.

Background. Clinical judgments about the likelihood of suicide attempt would be aided by an index of risk factors that could be quickly assessed in diverse settings. We sought to develop such a risk index for 12-month suicide attempts among suicide ideators.

Method. The National Comorbidity Survey Replication (NCS-R), a household survey of adults aged 18+, assessed the 12-month occurrence of suicide ideation, plans and attempts in a subsample of 5692 respondents. Retrospectively assessed correlates include history of prior suicidality, sociodemographics, parental psychopathology and 12-month DSM-IV disorders.

Results. Twelve-month prevalence estimates of suicide ideation, plans and attempts are 2·6, 0·7 and 0·4% respectively. Although ideators with a plan are more likely to make an attempt (31·9%) than those without a plan (9·6%), 43% of attempts were described as unplanned. History of prior attempts is the strongest correlate of 12-month attempts. Other significant correlates include shorter duration of ideation, presence of a suicide plan, and several sociodemographic and parental psychopathology variables. Twelve-month disorders are not powerful correlates. A four-category summary index of correlates is strongly related to attempts among ideators [area under the receiver operator characteristic curve (AUC)=0·88]. The distribution (conditional probability of attempt) of the risk index is: 19·0% very low (0·0%), 51·1% low (3·5%), 16·2% intermediate (21·3%), and 13·7% high (78·1%). Two-thirds (67·1%) of attempts were made by ideators in the high-risk category.

Conclusions. A short, preliminary risk index based on retrospectively reported responses to fully structured questions is strongly correlated with 12-month suicide attempts among ideators, with a high concentration of attempts among high-risk ideators.

Two scales are described which have been found useful in the measurement of relevant behaviour characteristics of mentally handicapped people in large scale surveys. One scale rates according to levels of continence, ambulance, and the presence of specified disruptive behaviours, while the other reflects speech, self-help, and literacy abilities. This information has been found useful in the planning and implementation of services for the mentally handicapped.

Background. It has been proposed that inferences about the mental states of others are drawn after a referral to autobiographical memory. This study explored the relationship between autobiographical memory retrieval and performance on tests of theory of mind in people with schizophrenia.

Method. Fifty-nine people with a DSM-IV diagnosis of schizophrenia and 44 healthy participants matched for age, sex and estimated IQ were given the Autobiographical Memory Interview (AMI), two measures of theory of mind (ToM) and a logical memory test.

Results. There was clear evidence that the people with schizophrenia were under-performing on all tasks. Within the schizophrenia sample, robust relationships existed between the total scores achieved on the AMI and the ToM tasks. Furthermore, there was evidence that the participants with schizophrenia had a tendency to recollect odd or negative events when prompted by the standard questions of the AMI.

Conclusions. The results of this study indicate that when people with schizophrenia attempt to think about the beliefs and intentions of others they use analogical reasoning. Whether this approach is also adopted by other clinical and normal adult groups is a question for future research.

Background. The literature documents that functional impairment is associated with affective disorders. Nevertheless, the choice among thorough, yet brief, well-validated assessments of functional impairment is limited. The objective of this study was to evaluate the psychometric properties of a brief scale of functional impairment, the Range of Impaired Functioning Tool (LIFE–RIFT).

Method. The study sample included subjects who presented with major depressive disorder at intake into the NIMH Collaborative Depression Study (CDS). The LIFE–RIFT is composed of items that are included in the Longitudinal Interval Follow-up Evaluation (LIFE). The reliability and validity were examined using data from LIFE–RIFT assessments conducted at four points in time: 6, 12, 18 and 24 months after intake into the CDS.

Results. Cross-sectional one factor models accounted for the covariance structure among the four scale items. A longitudinal factor model, with an invariant factor structure over time, also fitted the data well and indicated that the scale items are measures of one construct, namely functional impairment. The internal consistency reliability of the scale was supported with alpha coefficients ranging from 0·81 to 0·83. The inter-rater reliability intraclass correlation coefficient (ICC) was 0·94. Mixed-effect linear regression models showed that those in episode were significantly more impaired than those in recovery. Furthermore, in analyses of predictive validity, impairment was positively associated with subsequent recurrence and negatively associated with subsequent recovery.

Conclusions. This psychometric evaluation provides empirical support for the reliability and validity of the LIFE–RIFT, a brief measure of functional impairment.

Background. Apathy is a frequent neurobehavioural sequel in patients with acquired brain damage and it may seriously affect outcome of rehabilitation.

Methods. Patients with traumatic brain injury, cerebrovascular insults and hypoxic brain injury, categorized into four lesion localization groups: left hemisphere damage (LHD); right hemisphere damage (RHD); bilateral hemispheric damage (BHD); and subcortical damage (SCD) were assessed with the Apathy Evaluation Scale (AES) and Montgomery and Åsberg Depression Rating Scale (MADRS). Heart rate and electrodermal activity were recorded in an experimental situation that exposed the patients to mental stressors in order to measure psychophysiological reactivity.

Results. Significant differences in level of apathy were found between diagnostic groups as well as between localization subgroups. SCD and RHD patients displayed most apathy. Factor analysis of MADRS revealed a three-factor solution; depressed mood, somatic symptoms and negative symptoms. Apathy was significantly correlated with negative symptoms in all localization subgroups, except among the BHD patients. Apathy was not correlated with depressed mood or somatic symptoms. Moreover, apathy was significantly correlated with heart rate reactivity, but not with electrodermal reactivity.

Conclusion. Apathy is common, its severity depending on diagnosis and localization of lesion. Apathy and depression in brain damaged patients share common features, but may be differentiated. The significant relationship between apathy and heart rate may provide a psychophysiological correlation of the disengagement, lack of interest and absence of emotional responsivity typically seen in apathy. The results have implications for the theoretical understanding of apathy and related negative symptoms, and for rehabilitation practice.

A double-blind clinical trial has been carried out to ascertain whether patients making a good recovery from depressive illness with tricyclic antidepressant medication derive any benefit from continuation of therapy with the same drug at a lower dose level. Of the 92 patients who entered the trial significantly fewer on active treatment relapsed during the six-month trial period: 22% as compared with 50% of patients receiving placebo. Patients with residual symptoms on entry to the trial derived more benefit from continuation therapy than patients who had made a complete recovery. The findings relate to a six-month trial period only, and any possible advantage of continuation therapy over a longer period remains uncertain.

Background. The patients' ability to appraise their quality of life in schizophrenia was studied by examining the reliability and the validity of self-rated quality of life estimates.

Methods. Sixty-three symptomatically stable patients with schizophrenia (DSM-IV) receiving maintenance treatment were evaluated over a 4-week period. The subjects were asked to appraise their quality of life at weekly intervals on a single item global quality of life measure, as well as the self-administered sickness impact profile. The patients' quality of life was also rated by a clinician using the social performance schedule and the global assessment scale of functioning; and clinical aspects such as the severity of psychotic symptoms, neurocognitive deficits, dose of medications, and side effects were documented with standardized measures.

Results. The results indicated that the patients' self-reports were highly consistent over the 4 weeks, and the quality of life ratings correlated significantly with the clinician's estimates. The patients' quality of life was predictably influenced by the severity of their symptoms, side effects, cognitive deficits and the dose of their antipsychotic medication, but the reliability of their reports was not materially affected by these factors.

Conclusions. It is concluded that clinically compliant and stable patients with schizophrenia can evaluate and report their quality of life with a high degree of reliability and concurrent validity, implying that self-report measures are potentially useful tools in clinical trials and outcome studies.