There is a high rate of depression in patients with medical or other psychiatric disorders. This comorbid depression is associated with an increased morbidity and mortality from medical illness, poor compliance with treatment, a worsening of somatic symptoms, and often a decrease in functional status. Several recent studies have demonstrated that comorbid depression is highly treatable and that effective treatment often enhances patients' adaptive coping with medical illness. However, when choosing antidepressant therapy, care must be taken to evaluate the patient's illness fully and to avoid potential drug-drug interactions and drug-related illness. This review investigates the use of antidepressants in depressed patients with medical and psychiatric disorders and their effect on prognosis and morbidity, and suggests that there is a place for the use of antidepressant medications in the treatment of comorbid conditions. Generally, the greater safety and tolerability of the selective serotonin reuptake inhibitors provides improved options for the treatment of depression in the medically and psychiatrically ill.

Whilst steady progress has been made in the development and dissemination of valid and reliable instruments for evaluation of patient outcomes, progress in establishing standard methodologies for description and classification of mental health services has been limited. Valid and reliable methods of describing and classifying services are needed in mental health services research for purposes including; i) comparison of levels of provision between catchment areas and countries; ii) reaching an understanding of the relationship between socio-demographic indicators and service use; iii) investigation of the degree to which one service may be substituted for another; iv) evaluating programme implementation; and v) understanding why different outcomes are observed from apparently similar treatment programmes. Where programmes of research encompass different countries, the need for methods of comparing the local service contexts is particularly acute. In this paper, the various contributions which have been made to the somewhat fragmented body of research in this area are reviewed, and the problems which have hampered the development of satisfactory instruments are discussed. A set of criteria for satisfactory service measurement methodologies is proposed: these include development of standard nomenclature and operational definitions of service types; clear demonstration of validity and reliability; comprehensiveness; and applicability and similar interpretation in a range of countries.

In order to assess the accuracy of schizophrenia diagnoses for genetic studies, we identified all schizophrenia patients (n = 492) in an isolated community with a diagnosis of schizophrenia in the Finnish Hospital Discharge Register (HDR) between 1969-1991. For the accuracy study we identified a sample of 73 patients from registers with Diagnostic and Statistical Manual (DSM)-III-R for schizophrenia (codes 295.10, 295.30, 295.60, 295.90) (n = 62) or “schizophrenia spectrum” diagnoses (295.40, 295.70, 297.10, 301.20, 301.22) (n = 11). When the operational criteria (DSM-III-R) were applied by two senior researchers using information from the original mental hospital records, 93% (68/73) of the cases fulfilled criteria for schizophrenia or schizophrenia spectrum. The results demonstrate that the schizophrenia diagnoses of the registers are accurate when a broad concept of schizophrenia is applied. When using operational DSM-III-R schizophrenia criteria, eight false positive cases were found among the 62 mental hospital schizophrenia diagnoses. Consequently, there may be a need to reassess schizophrenia diagnoses depending on the purpose of the study. We also found good agreement between DSM-III-R (kappa 0.93) and operational criteria (OPCRIT) diagnostic system (kappa 0.89) diagnoses, made by one researcher, compared with operational diagnoses. This indicates the possibility for the reliable use of one of these methods alone for diagnostic reassessment. The information in the HDR on primary diagnoses and on the dates of admission and discharge was accurately transferred from the hospital records.

As soon as Adolf Hitler came to into power in 1933, four laws on racial segregation and race protection were edicted between 1934 and 1935. Schizophrenia, manic-depressive psychoses, epilepsy and alcoholism were regarded as hereditary mental illnesses. These laws were responsible for the sterilisation of 350,000 individuals who were thought to be at the source of the propagation of hereditary illnesses which might endanger the health and the future of the Aryan Germans. On September 1, 1939, Action T4 was launched: it required that all the mentally ill be exterminated. This action, which was run by the highest level of the Reich's chancellery with the help of psychiatrists coming from all backgrounds including university professors, was supposed to grant a serene death to all the mentally ill considered as untreatable. The death sentences were carried out by the medical staff in psychiatric hospitals specially equipped with gas chambers. Following protests, Action T4 was officially stopped on August 24, 1941, but, in reality, continued until the end of the war. The death sentences were carried out using either lethal doses of medication or food deprivation. One hundred and fifty thousand individuals fell victim to that therapeutic extermination which played an economic role as important as the one deemed to social protection. Many German academics, researchers, psychiatrists, geneticians and anthropologists played and active part in these murders which were carried out in the name of Nazi ideology based upon the supremacy of the Northern Germanic race and the necessity to protect it from miscegenation, especially from Jews. In the final part of this paper, the author gives an explanation of the perversion of ethics carried out by German psychiatrists.

Two different methods were compared in the assessment of depressive symptomatology improvement: live naturalistic (N) performed by the patient's therapist, and from videotape record of structured clinical interview (VSI) assessed by an independent rater out of five psychiatrists.

Sixty-one newly admitted depressed inpatients, with a Montgomery and Asberg Depression Rating Scale (MADRS) total score above 20, were assessed before antidepressant treatment (DO), after 10 days (D10) and 4 weeks of treatment (D28). Assessments were based on the MADRS and the Depression Retardation Rating Scale (DRRS) for both N and VSI methods, and on the SCL-90-R for self-rating.

With the MADRS, the N method was shown to be more sensitive to symptomatology change than the VSI method, but the VSI method was more correlated to self-assessment than the N method was. However, these results were not replicated on the DRRS, for which an underscoring with the VSI method was evidenced as compared to the N method.

As shown in other studies, the poorest agreement between the two methods was evidenced at DO, suggesting a “novelty effect” particularly with the VSI method. This “novelty effect” may be all the more pronounced if a personality disorder is associated to depression. Consequently, information concerning each patient before rating videotapes is needed, as well as investigations in the field of depression and personality disorders.

The greater change observed in MADRS with the N method as compared to the VSI method, may be due non-specific factors related mostly to therapist expectations by comparison to neutral raters. This hypothesis should be tested in the placebo group of a double-blind study, and, if confirmed, the use of VSI methods, by minimising non-specific factors of improvement due to therapist expectations, may decrease the placebo response in antidepressant drug trials.

There is no accepted definition of what constitutes onset of antidepressant effect, and this limits evaluation of the validity of many comparative reports. In order to clarify the nature of the comparative methodology required, it is proposed that two distinct research questions are separated conceptually: 1) when do antidepressant drugs begin to clinically act? and 2) do all antidepressant drugs produce relief of symptoms in patients within a similar time period? A methodological distinction may also be made in terms of whether to assess the onset of effect of an antidepressant as having an absolute quality (“fast”) or as being fast relative to other treatments (“faster”). The choice of aim will help to define the methodological approach, the applicability of the findings and the difficulties to be addressed. Describing an antidepressant as showing a “fast” or “faster” onset of response requires that any description attempts to define (in terms that may be generalised) the nature of the comparison (faster than what?), the nature of the effect (faster to do what?) and the population in whom this effect may be expected (faster in whom?). Some details of methodological approaches are reviewed, and suggestions for study designs are made.

Dysthymia is the last diagnostic label introduced after a series of precursors to describe a disorder whose nosological status has long been dubious. The results of published epidemiological, as well as clinical studies about its presentation, course and outcome partly support the validity of this construct — although their interpretation is limited by methodological difficulties: same prevalence in many locations in the world, always lower than that of major depression, somewhat specific clinical pattern, course and outcome.

The emergency admissions to hospital care in six psychiatric services in four Nordic countries were explored as a part of a Nordic comparative study on sectorised psychiatry. One year treated incidence cohorts were used, with the total cohort comprising 2,454 patients. Of the 803 patients who were admitted to inpatient care during a 1-year follow-up, 82% had at least one emergency admission and 23% repeated emergency admissions. The definition for the repeated emergency admissions was at least two admissions during the follow-up. The mean length of stay in emergency inpatient care per treatment episode for this patient subgroup was 28 days. Their emergency inpatient episodes constituted 30% of all inpatient days during the follow-up. However, the variations between the services and diagnostic subgroups were large. The results of a logistic regression analysis indicated that the following variables predicted repeated emergency admissions: inpatient care at index contact, emergency outpatient contacts or no planned hospital admissions during the follow-up, psychiatric service, age under 45 years, and a diagnosis of psychosis, personality disorder or dependency. The repeated emergency admissions were related to the existence of a special service unit for abusers but not to the rates of outpatient staff or acute beds in the services, to geographical distances, referral practice or existence of emergency services.

This study aimed to investigate the psychological disorders following rape as well as the course of Post-Traumatic Stress Disorder (PTSD), and to determine clinical factors predictive of chronic PTSD. Seventy-three rape victims were observed in a systematic follow-up study over 1 year following rape using structured interview schedules. The frequency of PTSD was massive. The early disorders predicting PTSD 1 year after rape included somatoform and dissociative disorders, agoraphobia and specific phobias as well as depressive and gender identity disorders and alcohol abuse. Through stepwise logistic regressions, the following were found to be good models of prediction of chronic PTSD 1 year after rape: for the characteristics of the traumas, intrafamily rape, being physically assaulted outside rape, and added physical violence during rape; for the early psychological and behavioural attitudes, low self-esteem, permanent feelings of emptiness and running away; and for early mental disorders, agoraphobia and depressive disorders. Finally, among all these predictive factors, added physical violence during rape, low self-esteem, permanent feelings of emptiness and agoraphobia were shown to constitute a strong model of predictors. People presenting features such as the predictive factors of chronic PTSD found in the study should be asked about a history of rape and symptoms of PTSD.

Panic has not always been recognised as an exclusively psychiatric condition. Research in this area continued along separate medical and psychological axes until 1980, when the development of Diagnostic and Statistical Manual (DSM)-III criteria established the overall concept of panic disorder. The lifetime prevalence of DSM-III panic disorder and repeated panic attacks, defined as the average of individual estimates from six studies, are 2.7% and 7.1% of the general population, respectively. Females are almost twice as likely as males to suffer panic disorder, and about seven times as likely to suffer repeated panic attacks. Overall, panic disorder or panic attacks occur in up to one in ten of the general population. The prevalence of panic disorder and panic attacks, their associations with other conditions, and their time courses have been investigated in a prospective epidemiological study in Zurich, Switzerland, in which 591 individuals were followed for 15 years. The validity of panic disorder and panic attacks as genuine psychological phenomena are attested to by their positive associations with a family history of panic disorder, elevated risk of suicide, lifetime treatment for psychiatric disorders, and especially treatment with prescribed medication and substantial work and social impairment. Strong comorbidity exists between panic states and other psychiatric conditions, including depression (major depression, bipolar disorder and recurrent brief depression), agoraphobia, social phobia, specific phobia, and obsessive-compulsive disease. A lower degree of comorbidity is seen with alcohol and tobacco dependence. Comorbid conditions usually precede panic, except for alcohol abuse, which is usually secondary to episodes of panic. The prognosis of panic states is often optimistic, and chronic disease is present in less than half of sufferers. Both panic disorder and repeated panic attacks are common, serious and disabling conditions. Effective diagnosis and treatment of repeated panic attacks and panic disorder are of equal importance.

Recent advances in antipsychotic treatment of schizophrenia have offered several new compounds which avoid many of the limitations of the classical antipsychotics. These so-called ‘atypical’ antipsychotics have fewer extrapyramidal side effects, greater efficacy against negative symptoms and greater efficacy in otherwise treatment-resistant patients. However, the mechanism of action of these atypical antipsychotics is still unclear. The several receptors currently implicated in the pharmacological profile of these atypical antipsychotics include subtypes of those for dopamine, serotonin, noradrenaline, and acetylcholine among others. The current hypotheses for possible mechanisms of action of atypical antipsychotics are discussed along with the experimental correlates of antipsychotic efficacy in animal models.

There has been a growing interest in the quality of life (QoL) of the mentally ill, subsequently a number of instruments to measure QoL have been developed. One of the measures of QoL which has received considerable attention is the Lancashire QoL Profile (LQOLP). The present study investigated test-retest reliability and internal consistency in the Swedish translation of the LQOLP using a cross-sectional sample of 29 inpatients. The results showed that test-retest reliability of subjective life satisfaction in the nine life domains covered by the LQOLP was satisfactory in seven of the domains, and acceptable in two (social relations and religion). Test-retest reliability for total subjective satisfaction score, global well-being, and an interviewer rated QoL were all on a satisfactory level (r > 0.80). The internal consistency and homogeneity of the total subjective QoL scale and the nine life domain subscales was satisfactory except for the social relations scale, where it was somewhat low.

The introduction of ICD-10 has changed the diagnostic borders of affective disorders in clinical psychiatry. The current study presents the diagnostic concordance between ICD-8 diagnoses given in 1993 and ICD-10 diagnoses given in 1994 to the same patients admitted in both years, according to the Danish register of psychiatric admissions. In total, 1,487 patients received an ICD-8 diagnosis of manicdepressive psychoses in 1993 and were re-admitted in 1994. The majority of patients (84.0%) with a manic-depressive diagnosis according to ICD-8 received a diagnosis of affective disorder according to ICD-10. Patients with a diagnosis of affective disorder according to ICD-10 had previously been diagnosed as manic-depressive (69.6%), psychogenic psychoses (8.7%). personality disorders (5.5%) or neurosis (3.2%) according to ICD-8. The ICD-10 concept of affective disorder thus appeared broader and more comprehensive compared with ICD-8.

The different coping responses to three types of aversive events - future threats, acute events and chronic stress — may be modulated by 5HT projections. Dysfunction in these coping mechanisms could cause, respectively: generalised anxiety disorder, panic, and depression. This theory proposes that dorsal raphe nucleus projections to 5HT2 and 5HT1D receptors mediate anticipatory anxiety and normally motivate avoidance of threats. The brain aversion system may be held in check by dorsal raphe nucleus 5HT projections to mediate behavioural inhibition during anticipatory anxiety. Proximal aversive stimuli such as pain and asphyxia elicit the fight-flight reflex mediated by the amygdala-hypothalamic-periaqueductal grey brain aversion system. Panic attacks may thus be due to spontaneous activation of this system. Median raphe projections to 5HT1A receptors have been implicated in adaptation to chronic stress-resilence. There is good evidence that 5HT1A function breaks down in depression and causes the depressed state. Experimental tests of this theory suggest that viewing anxiety, panic, and depression as dysfunctions in neurochemically and anatomically specific coping systems is heuristically useful.

The issue of early onset of action (EOA) of an antidepressant was addressed by several authors. Unfortunately so far there is neither consensus nor convention on the definitions of EOA, or on measures and methods of assessments. There are several quite different approaches to the statistical analysis of the data. Our objective was to compare the results concerning EOA obtained by different statistical techniques applied on a data set which was generated by several independent conclusive double-blind, placebo controlled randomised trials with two antidepressants. The following statistical techniques were used: 1) statistically significant difference for the first time; 2) statistically significant and clinically relevant difference for the first time; 3) pattern analysis; 4) classical survival analysis without ‘sustained response’; 5) survival analysis with sustained response. The advantages and drawbacks of different methods are discussed.

The question of whether hypocholesterolemic treatment is associated with increased mortality due to suicide, violence and car accidents is controversial and of great importance. We investigated the effect of hypocholesterolemic dietary and drug therapy on dysphoric emotions. Twenty-five hypocholesterolemic men were started on a 3-month dietary modification plan; those who showed unsatisfactory cholesterol reduction were given, in addition, a hypocholesterolemic drug for up to 1 year. Lipid profile and change in dysphoric emotions were measured. During the whole period, a negative correlation was found between cholesterol level and depression. During the dietary period, a significant improvement in depression and guilt with no change in lipid profile was noted. Drug therapy significantly reduced cholesterol levels, with a trend toward increased depression (after 3 months) and a significant increase in aggression and guilt (after 1 year). We conclude that changes in dysphoric emotions occurring during hypocholesterolemic therapy cannot be completely explained by the changes in cholesterol levels.

Studies validating the clinical diagnoses of affective disorder recorded in case registers against research diagnostic criteria do not exist. In the present study, a random sample of 100 patients was selected among 21,734 patients who were recorded in the Danish Psychiatric Central Register with a diagnosis of manic-depressive psychosis at their first admission to psychiatric ward in a period from January 1, 1971 to December 31, 1993. Case notes from alt over Denmark were reviewed for all 100 patients and diagnoses were made with the use of OPCRIT. Patients who were still alive were contacted and interviewed face to face or by telephone. In total, 95 out of the 100 patients received an ICD-10 diagnosis of affective disorder computed with OPCRIT and confirmed at the interviews. Other clinical characteristics such as the age at onset and the number of affective episodes estimated from the register corresponded well with information from the case notes and the interviews.