This issue features an editorial on light therapy in non-seasonal depression, with a lead paper describing a trial reporting efficacy of this use, two other papers reporting treatment-related studies, and groups of papers reporting findings of longitudinal studies, and functional MRI and neuropsychology of psychiatric disorders.

The Committee on Chronotherapeutics was recently formed by the International Society for Affective Disorders (ISAD), which has asked us to provide a consensus review of chronotherapeutics (light and wake therapy) in affective disorders. We consider these non-pharmaceutical, biologically based therapies to be potentially powerful adjuvants ready for clinical application. We also stress the need for additional studies, both in-patient and out-patient, to broaden the evidence base for indications and efficacy.

Background. This randomized controlled trial investigates the efficacy of two non-pharmacologic treatments, bright light and high-density negative air ions for non-seasonal chronic depression. Both methods have shown clinical success for seasonal affective disorder (SAD).

Method. Patients were 24 (75%) women and 8 (25%) men, ages 22–65 years (mean age±S.D., 43·7±12·4 years), with Major Depressive Disorder, Single Episode (DSM-IV code, 296.2), Chronic (episode duration [ges ]2 years). Patients were entered throughout the year and randomly assigned to exposure to bright light (10000 lux, n=10), or high-density (4·5×1014 ions/s flow rate, n=12) or low-density (1·7×1011 ions/s, n=10, placebo control) negative air ions. Home treatment sessions occurred for 1 h upon awakening for 5 weeks. Blinded raters assessed symptom severity weekly with the Structured Interview Guide for the Hamilton Depression Rating Scale – Seasonal Affective Disorder (SIGH-SAD) version. Evening saliva samples were obtained before and after treatment for ascertainment of circadian melatonin rhythm phase.

Results. SIGH-SAD score improvement was 53·7% for bright light and 51·1% for high-density ions v. 17·0% for low-density ions. Remission rates were 50%, 50% and 0% respectively. The presence or severity of atypical symptoms did not predict response to either treatment modality, nor were phase advances to light associated with positive response.

Conclusions. Both bright light and negative air ions are effective for treatment of chronic depression. Remission rates are similar to those for SAD, but without a seasonal dependency or apparent mediation by circadian rhythm phase shifts. Combination treatment with antidepressant drugs may further enhance clinical response.

Background. The opportunity to study district-wide educational interventions on suicide rates is rarely available. In 1997, the authors carried out a district-wide training programme for primary care, accident and emergency, and mental health workers (47% of eligible staff trained), and demonstrated improvements in skills, attitude and confidence among the recipients of the training.

Method. Suicide rates (including definite suicides and undetermined deaths) and population statistics were collected for a district and region of England from official sources from 1993–2001. A before-and-after (1994–1996 and 1998–2000) training intervention analysis was conducted on suicide rates.

Results. The suicide rate in 1994–1996 was 8·8 per 100000 before our educational intervention and unchanged at 8·6 per 100000 in 1998–2000 after it (p=0·783).

Conclusion. Brief educational interventions to improve the assessment and management of suicide for front-line health professionals in contact with suicidal patients may not be sufficient to reduce the population suicide rate.

Background. Drop-out, often accompanied by treatment non-compliance, is common in psychiatric trials. Methodologists have criticized the use of a traditional intention-to-treat (ITT) approach in such cases, and have proposed alternative methods. We set out to describe and assess methods for estimation of a treatment effect when the trial is ‘broken’.

Method. We describe a stratified method of moments (SMOM) estimator that assesses treatment effects on subjects who are willing to comply with all the treatments under study. A simulation study and a re-analysis of data from an antipsychotics trial are used to compare SMOM to ITT, as-treated, and adequate estimators.

Results. The new estimator retains good statistical properties under different levels of non-compliance and drop-out mechanisms. The re-analysis indicates that SMOM yields more precise results.

Conclusions. Although the traditional ITT approach provides a valid method to estimate treatment effects, it can be biased in the presence of treatment non-compliance and drop-out. It is critical that researchers move beyond traditional approaches when trials are broken. A key first step is to consider non-compliance and drop-out as two independent phenomena, tracking and reporting rates separately.

Background. This paper sought to examine the relationship between sexual orientation and mental health in a New Zealand birth cohort studied to age 25 years.

Method. The analysis is based on a sample of 967 participants (469 males; 498 females) in the Christchurch Health and Development Study. As part of this study information was gathered on: (a) measures of sexual orientation, same-sex behaviour and sexual attraction obtained at ages 21 and 25 years; (b) measures of mental disorders and suicidal behaviours over the interval 21–25 years; (c) measures of childhood and family background.

Results. Latent class analysis was used to combine indicators of sexual orientation, same sex behaviour and attraction to form an empirically based classification of sexual orientation. The best-fitting model classified the sample into three groups: exclusively heterosexual orientation (87·6%); predominantly heterosexual but with same-sex inclinations or experience (9·6%); predominantly homosexual (2·8%). Proportionately more women than men were classified as predominantly heterosexual (14·2% v. 4·8% respectively) or predominantly homosexual (3·9% v. 1·5% respectively). Cohort members with a predominantly homosexual orientation had rates of mental disorder and suicidal behaviours that were between 1·5 and 12 times higher than for those with an exclusively heterosexual orientation. These associations persisted after adjustment for confounding. The associations between sexual orientation and mental health were more marked for males than females.

Conclusions. The findings suggest a continuum of sexual preferences amongst young adults. Variations in sexual orientation were clearly associated with mental health. These associations tended to be stronger for males.

Background. The aim of this study was to examine the linkages between suicidal ideation and attempt in adolescence and subsequent suicidal behaviours and mental health in young adulthood.

Method. Data were gathered during the course of a 25-year longitudinal study of a birth cohort of 1265 New Zealand children. The information collected included: (a) measures of suicidal thoughts and attempts in adolescence (<18 years); (b) measures of suicidal ideation, suicide attempt, major depression, anxiety disorders, and substance use disorders in young adulthood (18–25 years); and (c) measures of childhood and family background, individual characteristics, and mental disorders in adolescence.

Results. After statistical adjustment for confounding factors, suicide attempt in adolescence was associated with increased risks of subsequent suicidal ideation (OR 5·7) suicide attempt (OR 17·8) and major depression (OR 1·5). Those reporting suicidal ideation without suicide attempt showed moderate increases in risks of later suicidal ideation (OR 2·5), suicide attempt (OR 2·0) and major depression (OR 1·6). In addition, there was evidence of an interactive relationship in which suicidal behaviour in adolescence was associated with increased risks of later substance use disorders in females but not males.

Conclusions. Young people reporting suicidal ideation or making a suicide attempt are an at-risk population for subsequent suicidal behaviour and depression. Further research is needed into the reasons for suicidal adolescent females being at greater risk of later substance use disorder.

Background. While several personality characteristics are implicated in the etiology and phenotypic expression of schizophrenia, little is known about their trait status or clinical correlates during the early course of this disorder.

Method. The stability of five personality characteristics derived from the MMPI-168 was examined in recent-onset schizophrenia patients (n=59) during a psychotic period at study entry and at two out-patient assessments over the following 15 months and in non-patient controls (n=39) at similar time intervals. Among patients, associations between personality characteristics and clinical symptoms and exposure to stressful life events during the study period were also examined.

Results. Multilevel modeling analyses indicated that the between-subjects or trait-like variance components for these characteristics among patients were substantial, albeit smaller than those found for controls. Patients reported higher mean levels of Neuroticism, Cynicism, and Psychotic Ideation and lower mean levels of Psychopathic Tendencies and Denial of Somatic Complaints than controls. Among patients, several personality characteristics were systematically related to mean clinical symptom levels as well as frequency of exposure to dependent, but not independent, life events.

Conclusions. Stable individual differences in personality are detectable during the early course of schizophrenia and may help account for heterogeneity in clinical symptoms and functional outcome.

Background. Failure to resist chronic obsessive–compulsive symptoms may denote an altered state of cognitive control. We searched for the cerebral regions engaged in this dysfunction.

Method. Differences in brain regional activity were examined by event-related functional magnetic regional imaging (fMRI) in a group of adolescents or young adults (n=12) with childhood-onset obsessive–compulsive disorder (OCD), relative to healthy subjects. Subjects performed a conflict task involving the presentation of two consecutive and possibly conflicting prime and target numbers. Patients' image dataset was further analysed according to resistance or non-resistance to symptoms during the scans.

Results. Using volume correction based on a priori hypotheses, an exploratory analysis revealed that, within the prime-target repetition condition, the OCD subjects activated more than healthy subjects a subregion of the anterior cingulate gyrus and the left parietal lobe. Furthermore, compared with ‘resistant’ patients, the ‘non-resistant’ OCD subjects activated a bilateral network including the precuneus, pulvinar and paracentral lobules.

Conclusions. Higher regional activations suggest an abnormal amplification process in OCD subjects during the discrimination of repetitive visual stimuli. The regional distribution of functional changes may vary with the patients' ability to resist obsessions.

Background. Functional MRI studies have begun to identify neural networks implicated in visuospatial working memory in healthy volunteers and patients with schizophrenia. The study of schizotypal personality disorder (SPD) provides regional analysis in unmedicated patients in the schizophrenia spectrum.

Method. Unmedicated patients with SPD by DSM-IV criteria and normal controls were assessed with fMRI while performing a visuospatial working-memory task. It required the subjects to retain the location of three dots located on the circumference of an imaginary circle and then respond to a query display in which one dot was presented and the subject required to press a button to indicate whether the probe dot location was previously displayed. Subject groups did not differ significantly in spatial memory scores. The exact Talairach and Tournoux coordinates of brain areas previously reported to show activation with spatial memory tasks were assessed.

Results. The majority of these locations showed BOLD response activation significantly less in patients during the memory retention period, including the left ventral prefrontal cortex, superior frontal gyrus, intraparietal cortex and posterior inferior gyrus. Regions in the right middle prefrontal and prestriate cortex showed greater activation at a trend level for patients with SPD than for normal controls. In addition, we replicated the findings of increased activation with the task in healthy volunteers in the premotor areas, ventral prefrontal cortex and parietal cortex.

Conclusions. SPD patients show decreased activation compared to healthy volunteers in key frontal regions and we also provided a partial replication of findings reported in healthy subjects.

Background. Demonstrating specific cognitive impairments in psychotic disorders is difficult. However, specific deficits in memory and executive functions have often been claimed. The Cambridge Neuropsychological Test Automated Battery (CANTAB) tasks of IDED attention-shifting (an executive task) and visuospatial paired associates learning (PAL, a memory task) require intact frontal and temporo-hippocampal functioning, respectively; both have been suggested as markers of disease progress in psychosis.

Method. Seventy-one subjects with a first-episode psychosis or at-risk mental state were assessed on these two tasks during referral to a specialist service, the Cambridge-based CAMEO early intervention team.

Results. Performance on the two tasks was dissociated. Poor performance on the PAL test was associated with increased symptom levels and poorer global function, while failure on the IDED executive test was not found to have significant clinical associations. Duration of illness was not associated with performance on either task.

Conclusions. Visuospatial PAL failure may be a marker of clinical severity at the onset of psychosis while IDED performance may reflect a more stable, trait-like impairment. Dissociated performance on the executive and associative learning tasks may reflect independent, neurally dissociated impairments that do not arise in a fixed order. This may explain some of the heterogeneity of cognitive function seen in early psychosis.

Background. Schizophrenia is associated with perceptual organization deficits and abnormal neuronal connectivity has been described in early visual areas. The purpose of this study was to investigate the functional integrity of lateral connections in early visual areas of patients with schizophrenia and type I bipolar disorder with a history of psychosis.

Method. Twenty-four out-patients with schizophrenia, 22 out-patients with bipolar disorder, and 20 healthy control subjects participated in the study. Using a computer-assisted psychophysical test, contrast thresholds were measured for centrally presented target stimuli (Gabor patches), which were surrounded by two collinear flankers. Target-to-flanker distances were 0, 1, 2, 3, 4, 6, 9 and 12λ. Psychophysical measures were contrast threshold changes at each target-to-flanker distance compared with baseline thresholds determined for isolated targets with no flankers. Clinical measures included IQ, positive, negative, and depressive symptoms.

Results. In patients with schizophrenia, flankers did not facilitate contrast detection for target stimuli at 2–6λ distances compared to controls [effect size (Cohen's d): 1·25–1·42]. The inhibitory effect of flankers (0 and 1λ) and contrast thresholds in the absence of flankers were spared. Patients with bipolar disorder did not differ from the controls. Medicated and non-medicated patients displayed similar performances. Positive and negative symptoms and depression did not correlate with contrast threshold values.

Conclusions. Excitatory lateral connections in early visual cortex are specifically impaired in patients with schizophrenia, which may contribute to perceptual disorders such as unclear seeing, partial or skewed sight, disrupted rectilinearity, and abnormal figure-ground segregation.

Background. While there are many studies showing working-memory deficits in schizophrenia there are only a few that disentangle impairments for working-memory subprocesses such as perceptual, attentional, mnemonic and executive function.

Method. In this study of delay-dependent memory, 55 patients with schizophreniform psychosis, 50 with established schizophrenia and 56 healthy controls were investigated. Using the delayed matching-to-sample task from the Cambridge Neuropsychological Test Automated Battery (CANTAB), performance deficits were found in both patient groups after controlling for age and pre-morbid IQ.

Results. Even after controlling for simultaneous matching-to-sample ability (i.e. perceptual matching), impaired performance in both patient groups was found as soon as the stimuli were no longer present. Impaired performance was not due to different types of errors in patients versus controls. Performance in both patient groups was comparable, except for a slight decrease of overall task performance. This suggests that the deficit is relatively stable during the course of the illness.

Conclusions. Our results suggest a deficit in patients with psychotic illness in the initial processes necessary to actively maintain information, such as the ability to form an internal representation of complex objects.

Background. Satisfaction with antipsychotic medication is an important outcome variable. To date, there is a lack of a well-established measure to quantify patient satisfaction with psychiatric medication. This paper describes the development, dimensionality, reliability and validity of the Satisfaction with Antipsychotic Medication (SWAM) scale.

Method. Clinical and academic experts devised a 33-item Likert scale satisfaction questionnaire. Following a pilot study in a sample of 69 people with schizophrenia, 315 people with schizophrenia on the caseload of local mental health services in three London boroughs completed the questionnaire. The dimensionality, internal consistency and validity of the devised instrument were assessed.

Results. Reliability of the SWAM scale was good for subscales and total scores. The α coefficient for the two subscales: treatment acceptability and medication insight were 0·92 and 0·84 respectively. The α coefficient for the SWAM scale total score was 0·91 and ranged from 0·92 to 0·90.

Conclusion. Testing of the psychometric properties of the SWAM scale demonstrate that it is a reliable instrument for measuring patient satisfaction with antipsychotic medication. The measure could be used in routine clinical practice in mental health services to assess patient satisfaction with psychiatric medication.

Background. The proposed revisions of the ICD and DSM diagnostic systems have led to increased interest in evaluation of diagnostic criteria. This report focuses on the DSM-IV requirement that episodes of generalized anxiety disorder (GAD) must persist for at least 6 months. Community epidemiological data are used to study the implications of changing this requirement in the range 1–12 months for estimates of prevalence, onset, course, impairment, co-morbidity, associations with parental GAD, and sociodemographic correlates.

Method. Data come from the US National Comorbidity Survey Replication (NCS-R), a US household survey carried out during 2001–2003. Version 3.0 of the WHO Composite International Diagnostic Interview (WMH-CIDI) was used to assess DSM-IV anxiety disorders, mood disorders, substance disorders, and impulse-control disorders.

Results. Lifetime, 12-month, and 30-day prevalence estimates of DSM-IV GAD changed from 6·1%, 2·9%, and 1·8% to 4·2–12·7%, 2·2–5·5%, and 1·6–2·6% when the duration requirement was changed from 6 months to 1–12 months. Cases with episodes of 1–5 months did not differ greatly from those with episodes of [ges ]6 months in onset, persistence, impairment, co-morbidity, parental GAD, or sociodemographic correlates.

Conclusions. A large number of people suffer from a GAD-like syndrome with episodes of <6 months duration. Little basis for excluding these people from a diagnosis is found in the associations examined here.