Background. No convincing explanation has been forthcoming for the variation in best threshold to adopt for the GHQ in different settings.

Methods. Data dealing with the GHQ and the CIDI in 15 cities from a recent WHO study was subjected to further analysis.

Results. The mean number of CIDI symptoms for those with single diagnoses, or those with multiple diagnoses, does not vary between cities. However, the best threshold is found to be related to the prevalence both of single and of multiple diagnoses in a centre. Variations in the diagnoses to be included in the ‘gold standard’ did not account for the variation observed. There was a strong relationship between area under the ROC curve (as a measure of the discriminatory power of the GHQ) and the best threshold, with higher thresholds being associated with superior performance of the GHQ. The items on the GHQ-12 that provided most discrimination between cases and non-cases varied from one centre to another.

Conclusions. The GHQ threshold is partly determined by the prevalence of multiple diagnoses, with higher thresholds being associated by higher rates of both single and multiple diagnosis. The mean GHQ score for the whole population of respondents provides a rough guide to the best threshold. In those centres where the discriminatory power of the GHQ is lowest, it is necessary to use a low threshold as a way of ensuring that sensitivity is protected, but the positive predictive value of the GHQ is then lower. Some of the variation between centres is due to variation in the discriminatory power of different items.

Background. Substantial variability in age at onset of illness and course of illness exists between patients with schizophrenia. Recent studies suggest that age at illness onset may be useful in defining biologically and clinically distinct subgroups of patients.

Methods. Two hundred and ten males with schizophrenia were classified as early-onset or adult-onset according to their age at first hospitalization. Birth history, clinical functioning and treatment response was assessed in a subgroup of patients. Brain anatomy was assessed from CT scans in all patients and in 32 non-psychiatric control subjects.

Results. Patients with an early-onset were likely to have a history of obstetric complications, a poor response to neuroleptic treatment, and showed no relationship between ventricle size and duration of illness. Adult-onset patients were less likely to have obstetric complications, more likely to respond to treatment in the first years of illness, and showed an association between brain structure and duration of illness.

Conclusions. The distinction between early- and adult-onset patients may have important aetiological and treatment implications.

Background. The liability to autism confers a risk for a range of more subtle autistic-like impairments, but it remains unclear whether it also confers a risk for other psychiatric disturbances.

Methods. To investigate this, we studied the pattern of familial aggregation of psychiatric disorders in relatives of 99 autistic and 36 Down's probands, using family history and direct interview measures.

Results. Family history data showed that motor tics, obsessive–compulsive (OCD) and affective disorders were significantly more common in relatives of autistic probands and that individuals with OCD were more likely to exhibit autistic-like social and communication impairments. Direct interview data confirmed the increased rate of affective disorders (especially major depressive disorder) in the first-degree relatives. There was no evidence to indicate significant co-morbidity between affective disorders and the broadly defined phenotype of autism. Moreover, the characteristics of the probands' and the relatives' that were associated with the liability to familiality of the broader phenotype of autism differed from those that predicted the liability to the familiality of affective disorders. Examination of the onset of affective disorders suggested that the increased risk was not confined to the period following the birth of the child with autism.

Conclusions. Overall, the results indicated that OCD, but not affective disorders, may index an underlying liability to autism. They also indicated that the increased risk of affective disorders was not solely the consequence of the stress of raising a child with autism and that further research will be required to clarify the mechanisms involved.

Background. The purpose of the present study was to examine the measurement properties of positive affect items among the Japanese population.

Methods. Responses to the Japanese version of the Center for Epidemiologic Studies Depression Scale and four additional negatively revised items of the original positive affect items were compared for 85 Japanese psychiatric out-patients with dysphoric-mood-related symptoms and 255 demographically matched controls.

Results. Responses to positive affect items were generally comparable between the two groups, whereas responses to negative symptom items were markedly different (P<0·002 for all comparisons). The group difference was most marked for symptom persistence. Responses to the four negatively revised items of positive affect revealed a similar picture to that of the negative symptom items. The internal consistency of the scale significantly improved when the original positive affect items were replaced by the negatively revised items (P<0·001 for both).

Conclusions. Positive affect items with positive wording cannot be used to assess depressive disorders in the Japanese population adequately, but this can be done with the corresponding negatively revised items.

Background. Increasingly, evaluations of mental health services include an economic component, although often only summary statistics such as the mean or median are reported. Measures of variation are often limited to the standard error or standard deviation, though costs are rarely normally distributed and vary substantially between patients. The aim of this study is to identify factors that can explain variations in the cost of mental health services for epidemiologically representative cases of psychosis.

Methods. Cases with ICD-10 diagnoses of functional psychosis were drawn from a sample that included all identified cases of psychosis in two geographically defined sectors in Camberwell, south London. Mental health service use was measured and costed. A predictive model was developed using multiple regression analyses, in which patient characteristics and previous service use indicators were used as predictor variables. Services were measured using the Client Service Receipt Interview.

Results. Among the 147 cases included, the amount of cost variation explained by the model was 31·5%. The most significant predictive factor was social functioning, which was highly negatively associated with cost.

Conclusions. Current mental health service use can be predicted to a reasonable extent by previous service use and patient characteristics, especially the degree of social disability. Identification of such factors can aid the effective allocation of scarce resources. In particular, subgroups of patients who use most resources can be identified and targeted by mental health services.

Background. There have been no previous studies of the outcome of different neurotic disorders in which a prospective group with original randomization to treatment have been followed up over a long period. Such studies are important in identifying the factors associated with good and poor outcome.

Methods. A 5-year follow-up assessment was made of a cohort of 210 psychiatric out-patients seen in general practice psychiatric clinics with a DSM-III diagnosis of generalized anxiety disorder (71), panic disorder (74) or dysthymic disorder (65) and randomized to drug treatment, cognitive and behaviour therapy, and self-help. A total of 182 of the patients (87%) were assessed after 5 years by examination of hospital and GP records using a standardized procedure and outcome determined with a four-point outcome scale.

Results. One hundred and seven (60%) of the patients had a favourable outcome but the remainder continued to be handicapped either intermittently or continuously throughout the 5-year period. Analysis of the value of initial data in predicting outcome using polychotomous step-wise logistic regression revealed that five variables were significant predictors of poor prognosis: older age; recurrent episodes; the presence of personality disorder at entry; general neurotic syndrome at entry; and symptom severity after 10 weeks. The initial DSM diagnosis and original treatment given, together with ten other variables, were of no predictive value.

Conclusions. The long-term outcome of neurotic disorder is better predicted by age, personality and recency of onset than by other clinical variables with the exception of initial response to treatment.

Background. Disturbances of serotonergic neurotransmission appear to be particularly important for the pathophysiology of winter depression. This study investigated whether fluoxetine has antidepressant effects comparable to bright light in the treatment of seasonal affective disorder (winter type).

Method. A randomized, parallel design was used with rater and patients blind to treatment conditions. One week of placebo (phase I) was followed by 5 weeks of treatment (phase II) with fluoxetine (20 mg per day) and a placebo light condition versus bright light (3000 lux, 2 h per day) and a placebo drug. There were 40 patients (20 in each treatment condition) suffering from seasonal affective disorder (SAD) according to DSM-III-R who had a total score on the Hamilton Depression Scale of at least 16.

Results. Forty patients entered phase II and 35 completed it (one drop-out in the fluoxetine group and four in the bright light group). Fourteen (70%) of the patients treated with bright light and 13 (65%) of those treated with fluoxetine were responders (NS). The remission rate in the bright light group tended to be superior (bright light 50%, fluoxetine 25%; P=0·10). Light therapy improved HDRS scores significantly faster, while fluoxetine had a faster effect on atypical symptoms. Light treatment in the morning produced a significantly faster onset of improvement, but at the end of treatment the time of light application seemed not to be crucial.

Conclusion. Both treatments produced a good antidepressant effect and were well tolerated. An apparently better response to bright light requires confirmation in a larger sample.

Background. Morphometry, the measurement of forms, is an ancient practice. In particular, schizophrenic somatology was popular early in this century, but has been essentially absent from the literature for over 30 years. More recently, evidence has grown to support the notion that aberrant neurodevelopment may play a role in the pathophysiology of schizophrenia. Is the body, like the brain, affected by abnormal development in these patients?

Methods. To evaluate global deficit in development and its relationship to pre-morbid function, height was compared in a large group (N=226) of male schizophrenics and a group of healthy male controls (N=142) equivalent in parental socio-economic status. Patients in the lower quartile of height were compared to those in the upper quartile of height.

Results. The patient group had a mean height of 177·1 cm, which was significantly shorter than the mean height of the control group of 179·4 (P<0·003). Those in the lower quartile had significantly poorer pre-morbid function as measured by: (1) psychosocial adjustment using the pre-morbid adjustment scales for childhood and adolescence/young adulthood, and (2) cognitive function using measures of school performance such as grades and need for special education. In addition, these measures of pre-morbid function correlated significantly with height when analysed using the entire sample.

Conclusions. These findings provide further support to the idea that abnormal development may play a key role in the pathophysiology of schizophrenia. Furthermore, this is manifested as a global deficit in growth and function resulting in smaller stature, poorer social skills, and deficits in cognitive abilities.

Background. A cardinal feature of schizophrenia is the sufferer's difficulty in interacting appropriately within the social milieu. This deficit has recently been associated with the concept of theory of mind, more commonly construed as a working model to understand behavioural patterns in autistic children. In this paper the complex relationships between theory of mind, IQ and psychoses are addressed.

Methods. Five experimental groups were used; non-psychiatric controls, affective disorder, schizophrenia with normal pre-morbid IQ, schizophrenia with pre-morbid IQ in the mildly learning disabled range, and mild learning disability with no history of psychiatric illness. All subjects were given a first order Theory of Mind Task and if successful, a second order Theory of Mind Task was then administered. All subjects were rated using the Positive and Negative Symptom Scale (PANSS).

Results. Subjects with schizophrenia and subjects with mild learning disability show impaired ability on a second order theory of mind task. However, when patients who are unable to answer reality questions are removed from the analysis specific impairment of theory of mind is only seen in subjects with schizophrenia. Furthermore, this impairment is relatively specific to particular psychopathological clusters in subjects with schizophrenia. Even though the same clusters of psychopathology are also seen in patients with affective disorder, their presence is not associated with poor second order theory of mind performance.

Conclusions. Impaired theory of mind on second order tests is specific to schizophrenia when compared to mild learning disability and affective disorder control groups. Subjects with schizophrenia and pre-morbid mild learning disability show greater impairment than subjects with schizophrenia and a pre-morbid IQ within the normal range.

Background. Self-esteem (SE), a widely used construct in the social sciences, is usually conceptualized as a reflection of socialization and interpersonal experiences that may differ considerably between the genders.

Methods. The Rosenberg self-esteem scale was assessed at personal interview in both members of 3793 unselected twin pairs (1517 male–male, 856 female–female and 1420 male–female) from the population-based Virginia Twin Registry. Gender effects on SE were assessed by both analysis of variance and biometrical twin modelling.

Results. The mean SE score was slightly but significantly lower in women v. men, and in women who grew up with a male v. a female co-twin. Twin modelling suggested that: (i) individual differences in self-esteem in both men and women were best explained by genetic and individual-specific environment factors; (ii) heritability estimates were similar in women (32%) and in men (29%); and (iii) the same genetic factors that influenced SE in women also influenced SE in men. Analyses supported the validity of the equal environment assumption for SE. The heritability of SE cannot be explained by the moderate correlation between SE and symptoms of depression.

Conclusions. These results are inconsistent with prominent gender-related aetiological models for SE, which postulate that individual differences arise from socialization experiences both within and outside the home of origin which differ widely for the two genders. Instead, a significant proportion of the population variance in SE is due to genetically-influenced temperamental variables that are the same in men and women.

Background. Recent research has focused upon the subdiagnostic level in an effort to derive more valid domains of psychotic disorder. This has led to the influential positive–negative dichotomy in schizophrenia being superseded by a three-syndrome model. The strategy of looking for syndromes within poorly validated diagnostic categories, such as schizophrenia, has limitations, particularly since it originated in, and has been largely restricted to, the more chronic subsamples.

Method. A representative sample of first episode psychosis (N=509), which includes the full spectrum of functional psychosis, was utilized to re-examine the dimensional structure of functional psychosis from first principles. Patients were assessed with the Royal Park Multidiagnostic Instrument for Psychosis (MIP), a comprehensive procedure that documents the psychopathology of the first episode in a clinically valid manner.

Results. Principal axis factor analysis was carried out on the tetrachoric correlation matrix of 92 core psychopathological items. A robust and clinically valid four-factor solution was obtained, comprising depression, mania and only two other factors. The first was a Bleulerian blend of negative symptoms, catatonic/motor symptoms and disorganization. The second was a combination of Schneiderian first rank symptoms, and other hallucinations and delusions. The data thus failed to support the three-syndrome model for non-affective symptoms in this population. A six-factor solution, although partially consistent with other studies, represented a more complex and confusing elaboration of the more clinically valid four-factor solution.

Conclusions. The findings have implications for the conceptualization of early psychosis, which need to be explored further in validation studies.

Background. Many studies have noted a strong association between poor social support and premature mortality. A limitation of such studies has been their failure to control adequately for confounders that damage both social supports and physical health.

Methods. A 50-year prospective multivariate study of 223 men was used to examine the possible causal relationships between social supports and health. Alcohol abuse, prior physical health and mental illness prior to age 50 were controlled. Relative social supports were quantified over the period from age 50 to 70.

Results. Adequacy of social supports from age 50 to 70 was powerfully correlated with physical health at age 70 (P<0·001). However, such social supports were also powerfully predicted by alcohol abuse (P<0·001), smoking (P<0·001) and indicators of major depressive disorder (P<0·01) assessed at age 50. When prior smoking, depression and alcohol abuse were controlled, then the association of physical health with social supports was very much attenuated. Some facets of social support like religion and confidantes were unassociated with health even at a univariate level. Surprisingly, in this sample friends seemed more important for sustained physical health than closeness to spouse and to children.

Conclusions. While social supports undoubtedly play a significant role in maintaining physical well-being in late life, much of the association between poor social supports and mortality may be mediated by alcoholism, smoking and pre-morbid psychopathology.

Background. Children with asthma are vulnerable to negative emotions, but clinical observations and research suggest that negative emotions can also be precipitants of asthma attacks. Empirical data provided mixed results. The hypothesis was tested that negative emotions influence subjective rather than objective symptoms of asthma, breathlessness and airways obstruction, respectively.

Methods. Forty asthmatic children (aged 7 to 18 years) were randomly assigned to one of four experimental conditions: 1, viewing an emotional film of 10 min; 2, performing standardized physical exercise of modest intensity up to a heartbeat of 170 b/min; 3, combination of conditions, order conditions, 1+2; and 4, combination of conditions, order conditions 2+1. Lung function, breathlessness and state anxiety were measured pre-test and post-test. Respiration sounds were recorded continuously for assessment of emotional breathing patterns.

Results. The data and responses to exit questions, confirmed a successful induction of anxiety via increased state anxiety and respiratory rate. Viewing the emotional film did not by itself enhance airways obstruction or breathlessness. Airways obstruction and breathlessness increased significantly after exercise only. Significantly more breathlessness was reported when negative emotions preceded exercise. Breathlessness was statistically independent of lung function, severity of asthma, symptoms in the past 4 weeks, anxiety or age.

Conclusion. Negative emotions affect subjective, rather than objective symptoms of childhood asthma. It was suggested that children in a negative emotional state, uncertain about the condition of their airways, are inclined to interpret exercise-related general sensations (fatigue, heart pounding, sighing) in line with expectations as symptoms of airways obstruction. Consequently, they may report relatively high breathlessness, irrespective of actual objective symptoms of asthma.

Background. Capacity limitation theories have proved to be surprisingly resilient in characterizing some of the cognitive deficits in schizophrenia. However, this perspective has not generally been applied to short-term verbal memory tasks. We explored this issue by first attempting to ascertain if gross misallocations of processing resources might explain impairments in short-term memory in schizophrenia on a classic digit span task and in a second study by attempting to determine what effects delay and memory set size had on a divided attention short-term verbal memory paradigm.

Methods. In the first study 16 patients with schizophrenia and 21 normal controls received 40 trials of a three digit task and 20 trials of a six digit span task. As the absolute number of digits presented and duration of presentation in two conditions were identical, subjects thus had equivalent ‘opportunities’ to make errors if distraction, in the sense of misallocation of cognitive resources, were at the root of poor performance. In the second study 15 patients with schizophrenia and 15 normal controls were tested in conditions in which two, four or six words were presented and in which rehearsal was prevented by an interference task (colour naming) for delays of 5, 10 or 15 s.

Results. Patients had disproportionate difficulty on the six digit rather than the three digit condition, suggesting that deficits in the verbal working memory short-term store may not be the result of attentional factors. In the second study, patients' performance was differentially worsened by the interference task, by memory set size (i.e. a capacity limitation) and by delay, a measure of decay rate.

Conclusions. In concert, these studies demonstrate that schizophrenia patients have difficulties on verbal short-term memory span tasks not because of misallocation of resources, but rather because of limitations in ‘representational capacity’ and maintenance of information over delays.

Background. Past studies have found inconsistent evidence that substance use disorders are related to earlier onset of schizophrenia or more severe symptoms. This study examines prevalence and severity of current substance use disorders and onset of psychotic illness in a multi-facility sample.

Methods. Data are from the Suffolk County Mental Health Project, an epidemiological study of first admission psychosis. The SCID and instruments measuring symptomatology, personality and background characteristics were administered. Respondents were stratified into three groups: (a) no life-time substance diagnosis; (b) in remission or reporting current mild use at admission; and (c) current moderate–severe substance abuse at admission.

Results. Using the SCID severity rating, 17·4% of males and 6·2% of the females had moderate or severe current substance abuse, while 41·5% of males and 68·2% of females had no lifetime substance diagnosis. In almost all cases categorized as moderate–severe, the substance diagnosis predated onset of psychosis. Females categorized as moderate–severe had an earlier age of onset of psychosis than did females in the other groups. There were only slight differences in symptom severity among the groups but more marked antisocial behaviour in the moderate–severe group. Variables discriminating the moderate–severe from non-abuse groups were BPRS thought disturbance, adult anti-social behaviour and current cigarette smoking for males and adult antisocial behaviour and child–teen antisocial behaviour for females.

Conclusions. Severity of substance abuse does not appear to be a pivotal correlate of the early features of psychotic illness.

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.

Background. Frith & Done (1988) have proposed that the experience of alien control symptoms in schizophrenia is related to a failure by such individuals to monitor effectively their own willed intentions, actions and thoughts.

Method. To examine this hypothesis, a heterogeneous group of 35 patients, all carrying a DSM-III-R diagnosis of schizophrenia (or schizophreniform psychosis) and 24 non-patient controls, completed a battery of neuropsychological and cognitive tests, which inter alia, included four putative measures of self-monitoring. Patients took part in a detailed clinical interview to assess current levels of symptomatology.

Results. Patients generally performed at a lower level on most components of the test battery, including the four self-monitoring tests. Moreover, patients currently experiencing symptoms of alien control tended to experience greater difficulty with each of the self-monitoring tests; an effect that was relatively independent of neuropsychological or general cognitive function.

Conclusions. The relationship between poor self-monitoring and the presence of alien control symptoms provides support for Frith & Done's account of the origins of these symptoms in schizophrenia.

Background. Analysing costs measures in conjunction with psychiatric case register (PCR) data can provide important epidemiologically-based information on resource utilization. Costing the service use patterns of first-ever patients can indicate the shape and likely resource consequences for mental health services operating within a community-based system of care.

Methods. Yearly costs were calculated for the 299 first-ever patients and 768 longer-term patients who contacted the South-Verona Psychiatric Case Register between 1 January 1992 and 31 December 1993. Bivariate and multivariate analyses were used to compare costs between these groups and to test the associations between costs and the sociodemographic and diagnostic data recorded on the PCR.

Results. For all diagnostic groups identified, first-ever patients were found to be less costly to support than longer-term patients, even after adjustment for various factors, including whether patients were single consulters. When multivariate analyses were employed, between 20% and 69% of the cost variation for first-ever patients could be explained by patient and other characteristics, and the effect of the contact (first or subsequent) variable was reduced.

Conclusion. This study considered only the costs to the specialist psychiatric services but the methodology allows the likely annual resource implications of supporting new patients to be predicted from data collected at first contact. Such information can help ensure that services are adequately funded and that the resources are deployed appropriately between client groups.

Background. Despite a growing literature pointing to the deleterious health effects of sexual and physical abuse history, few studies provide evidence about which medical symptoms are most affected. The aim of this paper is to determine the impact of sexual and physical abuse history on a selected set of medical symptoms, and to test how such abuse, medical symptoms and functional disability may affect subsequent health care visits.

Methods. We studied 239 women from a referral-based gastroenterology clinic; follow-up data were available on 196 of these women. All women were interviewed about sexual and physical abuse history.

Results. Women with abuse history, particularly those with severe abuse, were much more likely to report somatic symptoms related to panic (e.g. palpitations, numbness, shortness of breath), depression (e.g. difficulty sleeping, loss of appetite), musculoskeletal disorders (e.g. headaches, muscle aches), genito-urinary disorders (e.g. vaginal discharge, pelvic pain, painful intercourse), skin disturbance (e.g. rash) and respiratory illness (e.g. stuffy nose). Furthermore, we found that the severity of abuse history, somatic symptoms and functional disability predicted 30% of the variance in health care visits during the subsequent year, and that the effect of abuse severity on visits was explained by abused women having more somatic symptoms and functional disability.

Conclusions. Patients' reports of abuse history, somatic symptoms and functional disability appear to be important factors in explaining the number of health care visits among a clinic sample of women with gastrointestinal disorders.

Background. The number of antidepressant drugs available in the market has grown rapidly in the last few years. The present paper underlines some of the pre-clinical and clinical problems that call close attention from the regulatory authorities when approving new drugs.

Methods. We present here a review of the literature.

Results. A wide heterogeneity in the action of the various antidepressants precludes any single theory about the pathogenesis and therapy of depression. Antidepressant activity, in fact, may be achieved by acting on a number of different monoaminergic mechanisms. The variety in the neurochemical effects of antidepressants is not reflected in clinical trials, which tend to stereotypy. In many cases clinical trials aim at demonstrating equivalence rather than differences in efficacy. Regulatory authorities should, therefore, pay attention in accepting the equivalence of effects of a new drug in relation to a reference one: most clinical trials of new antidepressant drugs do not have the power to detect clinically relevant differences.

Conclusions. Unconventional new pre-clinical tests are needed to generate antidepressants with a different mechanism of action. Clinical studies are needed to promote objective comparative evaluation of the cost, benefits and toxic effects of new antidepressants.