There is now a considerable body of epidemiological evidence from developing countries and multilateral agencies that so called common mental disorders are common and disabling (e.g. Murray & Lopez, 1996; Patel et al. 1998). The logical next step is to identify efficacious and cost-effective health services interventions that can tackle the all-important ‘so-what’ question that is posed by doctors and policy makers in developing countries when confronted with startling prevalence statistics. The rise of evidence-based medicine has highlighted the need for quality trials that can inform and guide clinical practice. This editorial poses the question of whether we need treatment evidence from developing countries. The key issue is whether we can assume that psychiatric treatment evidence can be applied from one culture, or region, to another. If, for example, this was possible, then clinical practice in developing countries could be fairly well informed by trials conducted in the West. However, there are several factors that limit the cross-cultural applicability of treatment research in psychiatry.

Background. Research on the management and the outcome of treatment of medically unexplained symptoms is very limited. Development of simple but effective techniques for treatment and demonstration of their effectiveness when applied in primary health care are needed.

Methods. A randomized controlled trial was carried out with follow-up assessments at 3 months after baseline assessments using the Short Explanatory Model Interview (SEMI), General Health Questionnaire (GHQ-30), Bradford Somatic Inventory (BSI) and patient satisfaction on a visual analogue scale. The study was carried out in a general out-patient clinic in Sri Lanka.

The intervention group received six, 30 min sessions based on the principles of cognitive behavioural therapy over a period of 3 months. The control group received standard clinical care.

Results. Eighty patients out of the 110 patients referred, were eligible. Sixty-eight were randomly allocated equally to the control and treatment groups. All 34 in the treatment group accepted the treatment offer and 22 completed between three and six sessions. At 3 months, 24 in the treatment and 21 in the control group completed follow-up assessments. Intention-to-treat analysis revealed significant differences in mean scores of outcome measures (adjusted for baseline scores) between control and intervention groups respectively – complaints 6·1 and 3·8 (P = 0·001), GHQ 10·4 and 6·3 (P = 0·04), BSI score 15·6 and 13·2 (P [les ] 0·01), visits 7·9 and 3·1 (P = 0·004).

Conclusions. Intervention based on cognitive behavioural therapy is feasible and acceptable to patients with medically unexplained symptoms from a general out-patients clinic in Sri Lanka. It had a significant effective in reducing symptoms, visits and distress, and in increasing patient satisfaction.

Background. There is extensive evidence of statistical associations between family discord/maladaptation and antisocial behaviour in the children, but questions remain on the extent to which the psychopathological risks are genetically or environmentally mediated.

Methods. Twin pairs (N = 1350), aged 8 to 16 years, in the general population-based Virginia Twin Study of Adolescent Behavioral Development were assessed using the Child and Adolescent Psychiatric Assessment interview administered separately to both twins and both parents. Structured interviews for parental lifetime psychiatric disorders were also administered to the mothers and fathers. Maternal reports on Olsson's Family Adaptability and Cohesiveness questionnaire and the Dyadic Adjustment Scale were used as indices of the family environment. A path analytical model based on an extended twin-family design was used to test hypotheses about parent–offspring similarity for conduct disorder symptomatology.

Results. Family discord and maladaptation, which intercorrelated at 0·63, were associated with a roughly two-fold increase in risk for conduct disorder symptomatology. When parental conduct disorder was included in the model the environmental mediation effect for family maladaptation remained, but that for family discord was lost.

Conclusion. It is concluded that there is true environmental mediation from family maladaptation, operating as a shared effect, which accounts for 3·5% of the phenotypic variance. The assumptions underlying this genetic research strategy are made explicit, together with its strengths and limitations.

Background. Rates of child and adolescent conduct disorder (CD) have increased steadily over the past several decades. What is not known is whether the underlying genetic and environmental influences on individual differences in CD have also changed.

Methods. Retrospective reports of antisocial behaviour prior to age 18 were obtained from a population-based sample of 2769 adult males from male–male twin pairs born between 1940 and 1974. Using a summary score of number of CD symptoms, structural equation modelling was used to investigate whether mean level and variation in CD increased with more recent cohorts, and whether any increase in variance could be explained by familial or non-familial factors.

Results. Both mean level CD symptoms and variation were increased in more recent cohorts. Model fitting indicated that the primary increase in variance was due to familial factors, most notably, an increase in the shared environmental influences on CD, from 0·01 (95% CI = 0·00; 0·27) to 0·30 (95% CI = 0·01; 0·44). Heritability estimates remained largely unchanged, although an increase in genetic factors could not be ruled out.

Conclusions. Secular changes in sociodemographic factors responsible for increasing rates of CD may also account for the greater magnitude of shared environmental influences on variation in CD found among more recent cohorts.

Background. As previous studies with homosexual males have revealed a later birth order, more older brothers and more brothers than sisters, this research was extended to a large series of transsexual males and females, some of whom are homosexual.

Methods. The male sample comprised 442 male-to-female transsexuals, subdivided by sexual partner preference: 106 homosexual, 135 heterosexual, 155 bisexual and 46 asexual. One hundred female-to-male transsexuals were also studied: 75 homosexual, 16 bisexual, seven heterosexual and five asexual. Birth order was computed by both Slater's Index and Berglin's Index.

Results. Homosexual male-to-female transsexuals have a later than expected birth order and more older brothers than other subgroups of male-to-female transsexuals. Each older brother increases the odds that a male transsexual is homosexual by 40%.

Conclusions. Hypotheses explaining the extension of prior findings to this large sample of transsexual males include a progressive maternal immunization to the male foetus either through the H-Y antigen or protein-bound testosterone or alterations in foetal androgen levels in successive pregnancies, all modifying male psychosexual development. Data on the sexual orientation of younger brothers of homosexual male transsexuals in this study are not consistent with the progressive immunization hypothesis.

Background. This report attempted to replicate and extend prior work examining social phobia (SP), co-morbid psychiatric illnesses, and the risk of suicidal ideation and suicide attempts incurred by their adolescent sufferers.

Methods. SP, alcohol dependence (ALD) and major depressive disorder (MDD) diagnoses, and suicide-related symptoms, were assessed in a population-based adolescent female twin sample. The differentiation of risks as a function of co-morbidity was explored. A trivariate model was fitted to estimate sharing of genetic and environmental vulnerability between SP and co-morbid disorders.

Results. The lifetime prevalence of SP was 16·3%. Significant risk for co-morbid MDD (OR = 3·2) and ALD (OR = 2·1) was observed. Strong evidence for shared genetic vulnerability between SP and MDD (respective heritabilities 28%, 45%; genetic r = 1·0) was observed with moderate support noted for similar sharing between SP and ALD (genetic r = 0·52, heritability for ALD 63%). SP with co-morbid MDD was associated with elevated risk for ALD and for suicide-related symptoms.

Conclusions. SP is a common illness often followed by co-morbid MDD and ALD. SP with co-morbid MDD predicts a substantially elevated risk of ALD and suicide-related symptoms, stressing the need for early SP detection.

Background. Suicide prevention is a health priority in many countries. Improved management of suicide risk may improve suicide prevention. This study aimed to assess the feasibility of health district-wide training in the assessment and management of people at risk of suicide; and to assess the impact of training on assessment and management skills.

Methods. Staff in three health care settings, namely primary care, accident and emergency departments and mental health services (N = 359), were offered suicide risk management training in a district-wide programme, using a flexible ‘facilitator’ approach. The main outcomes were the rate of attendance at training, and changes in suicide risk assessment and management skills following training.

Results. It was possible to deliver training to 167 health professionals (47% of those eligible) during a 6 month training period. This included 95 primary care staff (39%), 21 accident and emergency staff (42%) and 51 mental health staff (78%). Of these, 103 (69%) attended all training. A volunteer sample of 28 staff who underwent training showed improvements in skills in the assessment and management of suicide risk. Satisfaction with training was high. The expected costs of district-wide training, if it were able to produce a 2·5% reduction in the suicide rate, would be £99747 per suicide prevented and £3391 per life year gained.

Conclusions. Training in the assessment and management of suicide risk can be delivered to approximately half the targeted staff in primary care, accident and emergency departments and mental health services. The current training package can improve skills and is well accepted. If it were to produce a modest fall in the suicide rate, such training would be cost-effective. However, a future training programme should develop a broader training package to reach those who will not attend.

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

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

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

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

Background. Different versions of the General Health Questionnaire (GHQ), including the GHQ-12 and GHQ-28 have been subjected to factor analysis in a variety of countries. The World Health Organization study of psychological disorders in general health care offered the opportunity to investigate the factor structure of both GHQ versions in 15 different centres.

Methods. The factor structures of the GHQ-12 and GHQ-28 extracted by principal component analysis were compared in participating centres. The GHQ-12 was completed by 26120 patients and 5273 patients completed the GHQ-28. The factor structure of the GHQ-28 found in Manchester in this study was compared with that found in the earlier study in 1979.

Results. For the GHQ-12, substantial factor variation between centres was found. After rotation, two factors expressing depression and social dysfunction could be identified. For the GHQ-28, factor variance was less. In general, the original C (social dysfunction) and D (depression) scales of the GHQ-28 were more stable than the A (somatic symptoms) and B (anxiety) scales. Multiple cross-loadings occurred in both versions of the GHQ suggesting correlation of the extracted factors. In Manchester, the factor structure of the GHQ had changed since its development. Validity as a case detector was not affected by factor variance.

Conclusions. These findings confirm that despite factor variation for the GHQ-12, two domains, depression and social dysfunction, appear across the 15 centres. In the scaled GHQ-28, two of the scales were remarkably robust between the centres. The cross-correlation between the other two subscales, probably reflects the strength of the relationship between anxiety and somatic symptoms existing in different locations.

Background. The next generation of studies on antidepressant drug prescriptions in general practice needs to assess both the patterns of prescription and its appropriateness. This study aimed to assess the performance of the Personal Health Questionnaire (PHQ), a new questionnaire for detecting individuals with ICD-10 depressive disorders, to be used in association with companion instruments for assessing the ‘quality’ of antidepressant prescriptions in primary care settings.

Methods. The PHQ was completed by 1413 primary care attenders (100 were re-tested after 7–14 days) and 139 were selected and interviewed using the SCAN-2 and the 17-item HDRS. All data were analysed using appropriately weighted procedures to control for two-phase sampling design and non-response bias. Individual weights were estimated by logistic regression analysis and trimming strategy.

Results. PHQ internal consistency and test–retest on both Likert score and number of symptoms were high. The PHQ discriminated well between individuals with and without depressive disorders. A Likert score [ges ] 9 provided a good trade-off between sensitivity (0·78) and specificity (0·83). The screening accuracy of the PHQ in detecting subjects likely to benefit from antidepressant drug treatment (SCAN cases with a HDRS total score of 13 or higher) was satisfactory (ROC area 0·87; sensitivity 0·84; specificity 0·78).

Conclusions. The PHQ can be strongly suggested as an accurate and economic screener to identify primary care attenders at high risk of being clinically depressed. However, in order to identify patients requiring antidepressant drug treatment, a second-phase assessment of PHQ high scorers (total score of [ges ] 10), using the HDRS, is needed.

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. 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. 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. Eye Movement Desensitization and Reprocessing (EMDR) is a relatively new form of psychotherapy for post-traumatic stress disorder. We critically reviewed randomized controlled trials of EMDR.

Methods. A wide range of electronic databases and reference lists of articles obtained were searched and relevant experts were consulted. Studies were critically appraised according to established criteria.

Results. We found 16 published randomized controlled trials (RCTs) comparing EMDR with alternative psychotherapy treatments, variants of EMDR and with delayed treatment groups. Studies were generally small (mean number of patients = 35) and of variable methodological quality, with only five reporting blinding of outcome assessors to treatment allocation, and in some cases with high loss to follow-up.

In most cases EMDR was shown to be effective at reducing symptoms up to 3 months after treatment. In one case benefit was maintained up to 9 months and in another (uncontrolled) follow-up treatment effect was present at 15 months. Two studies suggest that EMDR is as effective as exposure therapies, three claim greater effectiveness in comparison to relaxation training, and three claim superiority over delayed treatment groups. Of the studies examining specific treatment components, two found that treatment with eyes moving was more effective than eyes fixed, while three studies found the two procedures to be of equal effectiveness.

Conclusion. The evidence in support of EMDR is of limited quality but results are encouraging for this inexpensive, simple therapy. Further research is warranted in larger samples with longer periods of follow-up.

Background. The pathophysiology of auditory hallucinations and delusions of control has been elucidated using functional imaging. Despite their clinical importance, there have been few similar attempts to investigate paranoid delusions. We have examined two components of social cognition (attentional and attributional biases) that contribute to the formation and maintenance of paranoid delusions, using functional magnetic resonance imaging (fMRI).

Method. Normal subjects performed tasks requiring attentional and attributional judgements. We investigated the neural response particularly associated with attention to threatening material relevant to self and with the ‘self-serving’ attributional bias.

Results. The determination of relevance to self of verbal statements of differing emotional valence involved left ventrolateral prefrontal cortex (left inferior frontal gyrus, BA 47), right caudate and right cingulate gyrus (BA 24). Attention to threatening material relevant to self differentially activated a more dorsal region of the left inferior frontal gyrus (BA 44). Internal attributions of events, where the self was viewed as an active intentional agent, involved left precentral gyrus (BA 6) and left middle temporal gyrus (BA 39). Attribution of events in a non ‘self-serving’ manner required activation of the left precentral gyrus (BA 6).

Conclusions. Anomalous activity or connectivity within these defined regions may account for the attentional or attributional biases subserving paranoid delusion formation. This provides a simple model for paranoid delusion formation that can be tested in patients.

Background. Cognitive deficits in schizophrenia have recently been ascribed to impaired representation and use of cognitive context. Context is defined as relevant information held temporarily in mind to mediate appropriate but often non-habitual responses.

Methods. Parallel studies in a variety of cognitive domains were designed in order to explore the generality of any schizophrenic deficit in context use. In all of the tasks (a Stroop task, a Continuous Performance Task and a cued spatial location task), we examined how performance was affected by the time for which contextual information must be held in mind, and by whether context or task demands were consistent or varying between trials. It was predicted that manipulation of these variables would produce tests especially sensitive to schizophrenic attentional problems.

Results. Predictions were partially confirmed. Although increasing contextual demands failed in most cases to produce disproportionate slowing of performance in patients, error data were largely in line with predictions. At the same time, the data did not suggest a simple unitary context deficit. Instead, different aspects of context – the time over which contextual information must be held in mind and the consistency of context – were differentially important in different tasks.

Conclusions. The cognitive impairments of schizophrenic patients cannot be simply characterized as a generalized context deficit. A more differentiated, if not task specific, picture of schizophrenic deficits is suggested.

Background. Causal, responsibility and blame attributions for positive and negative symptom behaviours were examined in 70 caregivers of persons with schizophrenia.

Methods. The majority of subjects belonged to self-help group organizations. The three types of attributions for positive and negative symptom behaviours were assessed by self-report questionnaires.

Results. The extent of patient responsibility did not differ between the two types behaviours. Intentionality and knowledge were equally important in predicting responsibility for positive symptom behaviours, while intent was the most important predictor of responsibility for negative symptom behaviours with the patient capacity playing a significant but minor role. The entailment model was not supported for the two types of behaviours.

Conclusions. Increased attention should be given to responsibility dimensions in assigning moral accountability to the patient. The entailment model should be further explored in problematical caregiving situations.

Background. Increased recall of categorical autobiographical memories is a phenomenon unique to depression and post-traumatic stress disorder, and is associated with a poor prognosis for depression. Although the elevated recall of categorical memories does not change on remission from depression, recent findings suggest that overgeneral memory may be reduced by cognitive interventions and maintained by rumination. This study tested whether cognitive manipulations could influence the recall of categorical memories in dysphoric participants.

Methods. Forty-eight dysphoric and depressed participants were randomly allocated to rumination or distraction conditions. Before and after the manipulation, participants completed the Autobiographical Memory Test, a standard measure of overgeneral memory. Participants were then randomized to either a ‘decentring’ question (Socratic questions designed to facilitate viewing moods within a wider perspective) or a control question condition, before completing the Autobiographical Memory Test again.

Results. Distraction produced significantly greater decreases in the proportion of memories retrieved that were categorical than rumination. Decentring questions produced significantly greater decreases in the proportion of memories retrieved that were categorical than control questions, with this effect independent of the prior manipulation.

Conclusions. Elevated categorical memory in depression is more modifiable than has been previously assumed; it may reflect the dynamic maintenance of a cognitive style that can be interrupted by brief cognitive interventions.

Background. Hip fracture is common in the elderly. Previous studies suggest that psychiatric illness is common and predicts poor outcome, but have methodological weaknesses. Further studies are required to address this important issue.

Methods. We prospectively recruited 731 elderly participants with hip fracture in two Leeds hospitals. Psychiatric diagnosis was made within 5 days of surgery using the Geriatric Mental State schedule and other standardized instruments, and data on confounding factors was collected. Main study outcomes were length of hospital stay, and mortality over 6 months after fracture.

Results. Fifty-five per cent of participants had cognitive impairment (dementia in 40% and delirium in 15%), 13% had a depressive disorder, 2% had alcohol misuse and 2% had other psychiatric diagnoses. Participants were likely to remain in hospital longer if they suffered from dementia, delirium or depression. The relative risks of mortality over 6 months after hip fracture were increased in dementia and delirium, but not in depression.

Conclusions. Psychiatric illness is common after hip fracture, and has significant effects on important outcomes. This suggests a need for randomized, controlled trials of psychiatric interventions in the elderly hip fracture population.

Background. Patients who present with physical symptoms that lack an organic explanation are common, difficult to help and poorly understood. Their medical help-seeking is a form of care-eliciting behaviour and, as such, may be understandable in terms of attachment style. Adult attachment style influences functioning in relationships, and may affect help-seeking behaviour from professional carers such as the family doctor.

Method. A consecutive sample of 2042 primary-care attenders completed questionnaires on: the reason for consultation, attribution of symptoms, psychiatric distress (GHQ), somatic distress (BSI), and self-reported adult attachment style (ASQ). Their doctors rated presentations into explained physical, unexplained physical, or psychological.

Results. There is a powerful relationship between type of presentation and adult attachment style. Both abnormal attachment and level of psychiatric distress increased significantly from the explained physical group, through the unexplained physical group to the group who presented psychologically. Logistic regression models determined three explanatory variables that made significant independent contributions to presentation type: psychiatric distress, attachment style and symptom attribution.

Conclusion. Presentation to the doctor with unexplained physical symptoms is associated with both higher levels of psychiatric symptoms and abnormal attachment style when compared to presentations with organic physical symptoms. Patients who present overt psychological symptoms suffer more psychiatric distress and have more abnormal attachment than those presenting physical symptoms (either organically explained or unexplained). Models to explain these findings are discussed.