Background. In this paper we use data from the National Survey of Psychiatric Morbidity to examine how many people with neurotic disorders receive professional evaluation, and how this is affected by clinical and sociodemographic differences. We hypothesized that psychiatric symptoms and attendant dysfunctions would both have an effect on contacting, and that key demographic variables would not.

Method. The household component of the British National Surveys of Psychiatric Morbidity was based on a random sample of > 10000 subjects. Psychiatric symptoms and ICD-10 diagnosis were established by lay interviewers using the CIS-R. Social dysfunction was tapped by asking about difficulties in performing seven types of everyday activity. We examined symptom score, ADL deficit score and demographic variables in relation to contact with primary care physicians for psychiatric symptoms.

Results. The major determinant of contacting a primary care physician was severity, mainly due to the level of psychiatric symptoms, but with an independent contribution from social dysfunction. There were also significant contributions from sex, marital status, age, employment status and whether the subject had a physical condition as well.

Conclusions. The major influence on whether people seek the help of their family doctors for mental health problems is the severity of disorder. Although there are some social inequalities in access to family doctors, these are less important. The most salient finding from our study is that even people suffering from high levels of psychiatric symptoms very often do not have contact with professionals who might help them.

Background. Studies of groups of individuals who have a genetically high risk of developing schizophrenia, have found neuropsychological impairments that highlight likely trait markers of the schizophrenic genotype. This paper describes the change in neuropsychological function and associations with psychiatric state of high risk participants during the first two assessments of the Edinburgh High Risk Study.

Methods. Seventy-eight high risk participants and 22 normal controls, age and sex matched completed two neuropsychological assessments 18 months to 2 years apart. The areas of function assessed include intellectual function, executive function, learning and memory, and verbal ability and language.

Results. The high risk participants performed significantly worse on particular tests of verbal memory and executive function over the two assessments than matched controls. Those high risk participants who experienced psychotic symptoms were found to exhibit a decline in IQ and perform worse on tests of verbal memory and executive function than those without symptoms. An increase in psychotic symptoms between the two assessments in the high risk group was found to be associated with an apparent decline in IQ and memory.

Conclusions. The results suggest that the development of psychotic symptoms is preceded by a decline in IQ and memory. This may reflect a general and a more specific disease process respectively.

Background. The aim of this study was to develop a questionnaire that assessed the extent to which patients usually feel reassured by their attending physician.

Methods. The study population consisted of 204 subjects from the general population, 113 general practice patients, 130 general medical out-patients and 183 general medical patients with unexplained physical symptoms participating in an intervention study on the effect of cognitive behavioural therapy.

Results. Factor analysis yielded a one-factor solution. The internal consistency was moderate to high and the test–retest reliability was high. The convergent validity of the Reassurance Questionnaire (RQ) was satisfactory to good, but the scores on the RQ did not appear to differentiate between the general population, general practice patients and general medical out-patients. In medical out-patients with unexplained physical symptoms, the RQ discriminated well between hypochondriacal and non-hypochondriacal patients. Scores on the RQ tended to be associated with a bad outcome in terms of recovery of presenting symptoms at 1 year follow-up. There was no association between scores on the RQ and frequency of physician contact. In patients with unexplained physical symptoms treated with cognitive behavioural therapy, scores on the RQ decreased over a period of 6 months and 1 year.

Conclusions. The RQ was demonstrated to have psychometrically sound properties and appeared to be a useful instrument to assess reassurability in medical patients.

Background. We have recently reported a two-phase study on psychiatric morbidity in a sample of general hospital patients. This paper reports the results of the 6-month and 12-month follow-up of these patients.

Methods. The screening questionnaire was the GHQ-12. The main diagnostic instrument used in the second phase was the CIDI-PHC. All patients who had been interviewed with CIDI-PHC (N = 363) were followed-up and the baseline assessment was compared with the scoring on questionnaires administered in the 6-month postal enquiry and with the psychopathological status at 12-month, elicited with a telephone structured interview.

Results. Sixty-two and 87% of patients completed the 6- and 12-month follow-up assessment respectively. The first follow-up indicated no significant decrease in the level of symptoms. The 12-month follow-up interview showed that 23% of males and 40% of females had poor/mostly poor mental health. The logistic model showed that females with a definite ICD-10 diagnosis, admitted to a medical department, who had consumed psychotropic drugs in the previous year, had the most unfavourable outcome. The risk of a poor/mostly poor outcome steadily increased with the severity of the psychopathology during hospitalization.

Conclusion. In medical and surgical general hospital patients the risk factors associated with a poor mental health outcome are similar to those found in primary care patients. Greater attention should be paid in assessing routinely mental health status of general hospital patients during hospitalization.

Background. Many studies have suggested a possible aetiological role for obstetric complications in the development of schizophrenia. We focused on prenatal physical growth in schizophrenia, a contentious issue in the literature.

Methods. We compared gestational age at birth, birth weight (BW) and birth head circumference (BHC) between 312 schizophrenics and 517 controls, and between 187 schizophrenics and their matched healthy siblings. Information on obstetric histories was obtained from the Maternal and Child Health Handbooks (i.e. contemporaneous records).

Results. Gestational age at birth was significantly earlier in the schizophrenics than in the controls (P = 0·017). Pre-term birth (gestational age of 36 weeks or less) was more common in schizophrenics than in controls (8·0% v. 3·4%, P = 0·005, odds ratio 2·5). Low BW (2500 g or less) was more frequent in schizophrenics than in controls (9·6% v. 4·6%, P = 0·005, odds ratio 2·2). The schizophrenics had significantly lighter BW (P = 0·0003) and tended to have smaller BHC (P = 0·081) compared with controls. However, multiple regression analysis showed that there was no significant difference in BW or BHC between the schizophrenics and controls when gestational age and maternal weight were controlled. There was no significant difference in BW or BHC between schizophrenics and their siblings, although the schizophrenics tended to be born at earlier gestational age than their siblings.

Conclusions. Our results suggest that prematurity at birth is associated with a risk of developing schizophrenia in adulthood. When gestational age and maternal body weight were allowed for, there was no evidence that schizophrenics tend to have lower mean BW or smaller BHC.

Background. Previous 31P-MRS (magnetic resonance spectroscopy) studies suggested altered brain energy metabolism in bipolar disorder. This study characterized brain energy metabolism in lithium-resistant bipolar disorder using the photic-stimulation paradigm.

Methods. Subjects were 19 patients with DSM-IV bipolar disorder (nine responders and 10 non-responders, 13 with bipolar I and six with bipolar II) in the euthymic state and 25 healthy volunteers. Energy metabolism in the occipital region was examined by 31P-MRS during photic stimulation (PS). Six 31P-MR spectra were obtained, one was before PS (Pre), two during 12 min of PS (PS1, PS2), and three after the PS (Post 1, Post 2, Post 3).

Results. Significant effect of diagnosis (lithium-responsive bipolar disorder, lithium-resistant bipolar disorder, and control) was found for the phosphocreatine peak area ratio during the course of the photic stimulation (P<0·05 by repeated measures ANOVA). The phosphocreatine peak area ratio was significantly decreased at Post 1 and Post 2 compared with Pre in lithium-resistant bipolar patients (P = 0·01 and P = 0·01 by Dunnett's multiple comparison).

Conclusions. The finding that phosphocreatine decreased after photic stimulation may be compatible with mitochondrial dysfunction. It is possible that mitochondrial function is impaired in lithium-resistant bipolar disorder.

Background. Little work has been published on the internal structure of the Mini-Mental State Examination (MMSE), one of the most widely used instruments for grading cognitive status in clinical settings and field research.

Methods. MMSE responses from a sample of older adults (50–98 years) in five US sites (N = 8556) were analysed.

Results. A five-factor solution was found to be most appropriate. The first factor (concentration) had large loadings with serial sevens and spell world backwards items. The second factor (language and praxis) had large loadings with naming, follow command and praxis items. The third factor (orientation) had loadings with orientation to time and place items. The fourth factor (memory) had large loadings with delayed recall items and the fifth (attention) had large loadings with immediate registration items.

Conclusions. We found that the MMSE is essentially unidimensional; nevertheless, evidence was revealed suggesting that the MMSE is a multidimensional assessment instrument. Dimensions revealed in this sample correspond directly to MMSE sections articulated by the developers of the instrument. These findings have not been reported in previous factor analyses of the MMSE. The findings support the construct validity of the MMSE as a measure of cognitive mental state among community dwelling older adults.

Background. There has been limited research comparing the efficacy of different fatigue rating scales for use with individuals with chronic fatigue syndrome (CFS). This investigation explored relationships between two commonly-used fatigue rating scales in CFS research, the Fatigue Scale and the Fatigue Severity Scale. Theoretically, these scales have been described as measuring different aspects of the fatigue construct. The Fatigue Scale was developed as a measure of the severity of specific fatigue-related symptoms, while the Fatigue Severity Scale was designed to assess functional outcomes related to fatigue.

Methods. Associations of these scales with the eight definitional symptoms of CFS and with eight domains of functional disability were examined separately in: (1) an overall sample of individuals with a wide range of fatigue severity and symptomatology; (2) a subsample of individuals with CFS-like symptomatology, and, (3) a subsample of healthy controls.

Results. Findings revealed that both scales are appropriate and useful measures of fatigue-related symptomatology and disability within a general population of individuals with varying levels of fatigue. However, the Fatigue Severity Scale appears to represent a more accurate and comprehensive measure of fatigue-related severity, symptomatology, and functional disability for individuals with CFS-like symptomatology.

Background. Access to psychiatric treatment by people with neurotic disorders in the general population is likely to be affected both by the severity of disorder and by sociodemographic differences.

Method. In the household component of the National Surveys of Psychiatric Morbidity > 10000 subjects in Great Britain with psychiatric symptoms were interviewed using the CIS-R. They were also asked about difficulties experienced in performing seven types of everyday activity. All subjects classed as having an ICD-10 disorder were questioned about their experience of treatment with antidepressants, hypnotics, and counselling or psychotherapy.

Results. Less than 14% of people with current neurotic disorders were receiving treatment for them. Within the previous year, only a third had made contact with their primary care physician for their mental problem: of these < 30% were receiving treatment. Overall, 9% of people with disorders were given medication and 8% counselling or psychotherapy. A diagnosis of depressive episode was that most associated with antidepressant medication. Treatment access was affected by employment status, marital status, and age, but the major determinant was symptom severity. Neither sex nor social class influenced which people received treatment.

Conclusions. People with psychiatric disorders seldom receive treatment, even when they have consulted their primary care physician about them. In many cases, this must represent unmet needs with a strong claim on health resources. There are also inequalities in the receipt of treatment, although the major influence is the severity of disorder.

Background. While some cognitive accounts of disorganized speech, or thought disorder, in schizophrenia have emphasized failures in working memory/discourse planning or selective attention, we have suggested that thought disorder resides in the semantic system. In this study we assessed the effect of neuroleptic medication on thought disorder and semantic processing.

Methods. Seventeen patients with schizophrenia were assessed while receiving neuroleptic medications and in crossover fashion, placebo. A number of measures were obtained: clinically rated thought disorder (using the Thought, Language and Communication Scale); working memory (letter number span); lexical integrity (naming and receptive vocabulary); and, semantic priming of intracategorical word pairs.

Results. Semantic priming measures improved with neuroleptic medication, as did clinically rated thought disorder. No other measure changed significantly. Priming selectively covaried with changes in thought disorder.

Conclusion. Changes in spreading semantic activation, measured in a semantic priming paradigm and presumably brought about by neuroleptics' influence on dopaminergic neuromodulatory systems, might reflect changes in the biases of pre-existing associative networks that favour or increase the accessibility of representations related by shared features. This study also has implications for the architecture of normal language in that a dissociation between the lexical and semantic levels was observed, due to the selective compromise of tasks demanding semantic processing.

Background. There is little evidence to support possible structural changes in the amygdala and hippocampus of patients with severe depression.

Methods. Quantitative MRI of the amygdala and hippocampus, as well as proton spectroscopy (MRS) of mesial temporal structures were studied in 34 drug-resistant in-patients with major depression and compared with 17 age-matched controls. Volumetric MRI data were normalized for brain size.

Results. The volume of the left hippocampus was significantly smaller in the patients compared with the controls. Both groups exhibited similar significant hippocampal asymmetry (left smaller than right). The patients, but not the controls, had significant asymmetry of the amygdalar volumes (right smaller than left). No differences were observed between the patients and controls in the T2 relaxation times for the hippocampus and amygdala. Mesial temporal lobe MRS revealed a significantly elevated choline/creatine ratio in the patients compared with the controls.

Conclusions. This quantitative MRI study provides support for a possible association between structural and biochemical substrates and severe drug-resistant major depression.

Background. Poor physical health has long been recognized to be one of the most important risk factors for depression in older adults. Since many aspects of physical health can be targeted for improvement in primary care, it is important to know whether physical health problems predict the onset and/or the persistence of depression.

Methods. The study is based on a sample which at the outset consisted of 327 depressed and 325 non-depressed older adults (55–85) drawn from a larger random community-based sample in the Netherlands. Depression was measured using the Center for Epidemiologic Studies Depression scale (CES-D) at eight successive waves.

Results. From all incident episodes, the majority (57%) was short-lived. These short episodes could generally not be predicted by physical health problems. The remaining incident episodes (43%) were not short-lived and could be predicted by poor physical health. Chronicity (34%) was also predicted by physical health problems.

Conclusions. The study design with its frequent measurements recognized more incident cases than previous studies; these cases however did have a better prognosis than is often assumed. The prognosis of prevalent cases was rather poor. Physical health problems were demonstrated to be a predictor of both the onset and the persistence of depression. This may well have implications for prevention and intervention.

Background. Diverse forms of thought disorder, as measured by the Thought Disorder Index (TDI), are found in many conditions other than schizophrenia. Certain thought disorder categories are primarily manifest during psychotic schizophrenic episodes. The present study examined whether forms of thought disorder qualify as trait indicators of vulnerability to schizophrenia in persons who are not clinically ill, and whether these features could be linked to genetic or environmental risk or to genotype–environment interactions. The Finnish Adoptive Study of Schizophrenia provided an opportunity to disentangle these issues.

Methods. Rorschach records of Finnish adoptees at genetic high risk but without schizophrenia-related clinical diagnoses (N = 56) and control adoptees at low genetic risk (N = 95) were blindly and reliably scored for the Thought Disorder Index (TDI). Communication deviance (CD), a measure of the rearing environment, was independently obtained from the adoptive parents.

Results. The differences in total TDI between high-risk and control adoptees were not statistically significant. However, TDI subscales for Fluid Thinking and Idiosyncratic Verbalization were more frequent in high-risk adoptees. When Rorschach CD of the adoptive rearing parents was introduced as a continuous predictor variable, the odds ratio for the Idiosyncratic Verbalization component of the TDI of the high-risk adoptees was significantly higher than for the control adoptees.

Conclusions. Specific categories of subsyndromal thought disorder appear to qualify as vulnerability indicators for schizophrenia. Genetic risk and rearing-parent communication patterns significantly interact as a joint effect that differentiates adopted-away offspring of schizophrenic mothers from control adopted-away offspring.

Background. Minor depression is a disabling condition commonly seen in primary care settings. Although considerable impairment is associated with minor depression, little is known about the course of the illness. Using a variety of clinical and functional measurements, this paper profiles the course of minor depression over a 1 year interval among a cohort of primary care patients.

Method. Patients at a university-based primary care facility were screened for potential cases of depression and selected into three diagnostic categories: an asymptomatic control group; patients with a diagnosis of major depression; and, a third category, defined as minor depression, consisting of patients who reported between two and four symptoms of depression, but who failed to qualify for a diagnosis of major depression. Functional status, service use, and physical, social and mental health were assessed at baseline and at 3-month intervals for the ensuing year.

Results. Respondents with a baseline diagnosis of minor depression exhibited marked impairment on most measures both at baseline and over the following four waves. Their responses in most respects were similar to, although not as severe as, those of respondents with a baseline diagnosis of major depression. Both groups were considerably more impaired than asymptomatic controls.

Conclusions. Minor depression is a persistently disabling condition often seen in primary care settings. Although quantitatively less severe than major depression, it is qualitatively similar and requires careful assessment and close monitoring over the course of the illness.

Background. Dementia screening instruments, such as the Cambridge Cognitive Examination (CAMCOG), measure a variety of cognitive functions. However, memory impairment generally is the first sign of Alzheimer's disease (AD). It seems logical, therefore, to use only memory-related items for the early detection of AD. We divided the CAMCOG into a memory section and a non-memory section, and tested the hypothesis that the memory section predicts AD better than the non-memory section. We also provide normative data for both sections.

Methods. Normal subjects (N = 169) and patients with incident AD (i.e. satisfying AD criteria between 1 and 3 years from baseline; N = 25) were participants in the Amsterdam Study of the Elderly (AMSTEL), a population-based longitudinal study on cognitive decline and dementia. Patients with prevalent AD (i.e. satisfying AD criteria at baseline; N = 155) were either recruited in a memory clinic or came from AMSTEL. Normal subjects were cognitively intact at baseline and remained so for at least 3 years. The CAMCOG was administered to all subjects. AD was diagnosed by DSM-III-R criteria.

Results. Logistic regression analysis showed that the memory section was related to prevalent AD, whereas in multivariate analysis the non-memory section was not (after correction for the memory score and demographic characteristics). A similar analysis showed that the memory section predicted incident AD, as did a higher score on the non-memory section. The MMSE did not predict incident AD better than age alone.

Conclusion. For the early detection of AD it is best to use the memory and non-memory sections separately instead of the total CAMCOG score.

Background. To test the hypothesis that certain psychotic symptomatology is due to a defect in self- monitoring, we investigated the ability of groups of psychiatric patients to differentiate perceptually between self-produced and externally produced tactile stimuli.

Methods. Responses to tactile stimulation were assessed in three groups of subjects: schizophrenic patients; patients with bipolar affective disorder or depression; and normal control subjects. Within the psychiatric groups subjects were divided on the basis of the presence or absence of auditory hallucinations and/or passivity experiences. The subjects were asked to rate the perception of a tactile sensation on the palm of their left hand. The tactile stimulation was either self-produced by movement of the subject's right hand or externally produced by the experimenter.

Results. Normal control subjects and those psychiatric patients with neither auditory hallucinations nor passivity phenomena experienced self-produced stimuli as less intense, tickly and pleasant than identical, externally produced tactile stimuli. In contrast, psychiatric patients with these symptoms did not show a decrease in their perceptual ratings for tactile stimuli produced by themselves as compared with those produced by the experimenter. This failure to show a difference in perception between self-produced and externally produced stimuli appears to relate to the presence of auditory hallucinations and/or passivity experiences rather than to the diagnosis of schizophrenia.

Conclusions. We propose that auditory hallucinations and passivity experiences are associated with an abnormality in the self-monitoring mechanism that normally allows us to distinguish self-produced from externally produced sensations.

Background. We examined whether the relationships between hostility and physiological coronary heart disease (CHD) risk factors differ as a function of depressive tendencies (DT).

Methods. The participants were 672 randomly selected healthy young adults who self-reported their hostility (anger, cynicism, and paranoia) and DT. The physiological CHD risk factors studied were systolic blood pressure, diastolic blood pressure, body-mass index, serum high-density lipoprotein cholesterol, serum low-density lipoprotein cholesterol and serum triglycerides.

Results. We found that hostility was negatively associated with the physiological CHD risk factors among individuals exhibiting high DT while hostility was positively associated with, or unrelated to, the physiological risk factors among individuals showing low DT. The Hostility × DT interaction explained 2 to 5% of the variance in the physiological parameters.

Conclusion. The findings suggest that DT have a moderating influence on the relationships between hostility and CHD risk. Despite the established risk factor status of hostility, lack of anger and hostility, when combined with high DT, may represent the most severe exhaustion where the individual has given up. Disregard of this fact may explain some null findings in the research on hostility and CHD risk.

Background. This study examined the association between a diagnosis of traumatic grief and quality of life outcomes.

Method. Sixty-seven widowed persons were interviewed at a median of 4 months after their loss. The multiple regression procedure was used to estimate the effects of a traumatic grief diagnosis on eight quality of life domains, controlling for age, sex, time from loss and diagnoses of major depressive episode and post-traumatic stress disorder.

Results. A positive traumatic grief diagnosis was significantly associated with lower social functioning scores, worse mental health scores, and lower energy levels than a negative traumatic grief diagnosis. In each of these domains, traumatic grief was found to be a better predictor of lower scores than either major depressive episode or post-traumatic stress disorder.

Conclusions. The results suggest that a traumatic grief diagnosis is significantly associated with quality of life impairments. These findings provide evidence supporting the criterion validity of the proposed consensus criteria and the newly developed diagnostic interview for traumatic grief – the Traumatic Grief Evaluation of Response to Loss (TRGR2L).

Background. Systematic and accurate depiction of a patient's course of illness is crucial for assessing the efficacy of maintenance treatments for bipolar disorder. This need to rate the long-term prospective course of illness led to the development of the National Institute of Mental Health prospective Life Chart Methodology (NIMH-LCMTM-p or LCM). The NIMH-LCMTM-p allows for the daily assessment of mood and episode severity based on the degree of mood associated functional impairment. We have previously presented preliminary evidence of the reliability and validity of the LCM, and its utility in clinical trials. This study is a further and more extensive validation of the clinician rated NIMH-LCMTM-p.

Methods. Subjects included 270 bipolar patients from the five sites participating in the Stanley Foundation Bipolar Network. Daily prospective LCM ratings on the clinician form were initiated upon entry, in addition to at least monthly ratings with the Inventory of Depressive Symptomatology-clinician rated (IDS-C), the Young Mania Rating Scale (YMRS) and the Global Assessment of Functioning (GAF). We correlated appropriate measures and time domains of the LCM with the IDS-C, YMRS and GAF.

Results. Severity of depression on the LCM and on the IDS-C were highly correlated in 270 patients (r = −0·785, P < 0·001). Similarly, a strong correlation was found between LCM mania and the YMRS (r = 0·656, P < 0·001) and between the LCM average severity of illness and the GAF (r = −0·732, P < 0·001).

Conclusions. These data further demonstrate the validity and potential utility of the NIMH- LCMTM-p for the detailed daily longitudinal assessment of manic and depressive severity and course, and response to treatment.

Background. In primary care consultations patients with emotional distress tend to give verbal cues or symptom reports with psychological or psychiatric contents. This study examined the cue behaviour defined not only by psychological, but also by medical, social and life episodes related contents in patients with and without emotional distress, recognized and not by their GP. The GP's verbal behaviour in relation to patients' cue emission was also investigated.

Method. For the six participating GPs two groups of matched pairs of patients (N = 238) were created. The two groups comprised either patients considered by GPs as being without emotional distress or patients considered as emotionally distressed. Within each pair, one patient was a case (GHQ-12 score > 2) and the other was the matched control (GHQ-12 score < 3). The medical interviews with these patients were transcribed and classified according to the Verona Medical Interview Classification System (VR-MICS).

Results. GHQ positive patients of both groups gave more cues in terms of total proportion than their matched controls (GHQ negative patients). The proportion of cues given by patients was related also to GP's verbal behaviour, increasing with closed psychosocial questions and decreasing with the use of active interview techniques. Attribution of emotional distress was more frequent when patients were high attenders and had a past psychiatric history. The content of cues changed in relation to GP's attribution: recognized patients gave more cues and more often with psychological content, patients not recognized as distressed gave mainly cues related to their lifestyle and life episodes.

Conclusions. To improve the recognition of those emotionally distressed patients most likely to be missed GPs should increase their attention to cues related to life style and life episodes.