This issue contains one review article with sets of papers examining various aspects of depression and physical illness, bipolar disorder, and schizophrenia, and four individual articles examining a variety of topics.

Background. This paper reviews and integrates the growing literature concerning the prevalence of and risk factors for suicidality in chronic pain.

Method. A series of systematic searches in MEDLINE and PsychINFO identified 12 relevant articles examining suicide, suicide attempts, and suicidal ideation in chronic pain. A selection of theoretical and empirical work identifying psychological processes that have been implicated in both the pain and suicide literature and which may be related to increased suicidality was also reviewed.

Results. Relative to controls, risk of death by suicide appeared to be at least doubled in chronic pain patients. The lifetime prevalence of suicide attempts was between 5% and 14% in individuals with chronic pain, with the prevalence of suicidal ideation being ~20%. Eight risk factors for suicidality in chronic pain were identified, including the type, intensity and duration of pain and sleep-onset insomnia co-occuring with pain, which appeared to be pain-specific. Helplessness and hopelessness about pain, the desire for escape from pain, pain catastrophizing and avoidance, and problem-solving deficits were highlighted as psychological processes relevant to the understanding of suicidality in chronic pain.

Conclusions. Programmatic research is urgently required to investigate the role of both general and pain-specific risk factors for suicidality, to examine how the psychological processes mentioned above mediate or exacerbate suicidality, and to develop enhanced interventions for pain patients at risk.

Objective. To examine the relative and combined impact of depressive and chronic physical conditions on functional status and health-care use in the general population.

Method. Canadian, representative, population-based cross-sectional survey (n=130880). Major depressive disorder (MDD) in the past 12 months was assessed by structured interview, and physical disorders, activity reduction, role impairment and work absence by self-report. The relative impact of MDD and six common chronic physical illnesses (asthma, arthritis, back problems, chronic obstructive pulmonary disease, heart disease and diabetes) was estimated using multivariate regression, adjusting for sociodemographic characteristics and overall chronic physical illness burden.

Results. After adjusting for sociodemographic characteristics, alcohol dependence and chronic physical illness burden, the presence of co-morbid MDD was associated with significantly greater (approximately double the) likelihood of health-care utilization and increased functional disability and work absence compared to the presence of a chronic physical illness without co-morbid MDD. This impact of MDD was seen across each of the six chronic physical illnesses examined in this study, with the strongest associations seen for work absence.

Conclusions. These observations confirm prior findings of a strong association at the population level between major depression and health-care use and role impairment among persons with chronic physical disorders. They also point to the significant impact of co-morbid major depression on health-care seeking, disability and work absence in persons with chronic physical illness, underscoring the need for greater efforts to design and test the impact of detection and treatment programs for such individuals.

Background and purpose. Depressive symptoms are frequently associated with heart failure (HF), but the brain mechanisms underlying such association are unclear. We hypothesized that the presence of major depressive disorder (MDD) emerging after the onset of HF would be associated with regional cerebral blood flow (rCBF) abnormalities in medial temporal regions previously implicated in primary MDD, namely the hippocampus and parahippocampal gyrus.

Method. Using 99mTc-SPECT, we measured rCBF in 17 elderly MDD-HF patients, 17 non-depressed HF patients, and 18 healthy controls, matched for demographic variables. Group differences were investigated with Statistical Parametric Mapping.

Results. Significant rCBF reductions in MDD-HF patients relative to both non-depressed HF patients and healthy controls were detected in the left anterior parahippocampal gyrus and hippocampus (ANOVA, p=0·008 corrected for multiple comparisons) and the right posterior hippocampus and parahippocampal gyrus (p=0·005 corrected). In the overall HF group, there was a negative correlation between the severity of depressive symptoms and rCBF in the right posterior hippocampal/parahippocampal region (p=0·045 corrected).

Conclusions. These findings are consistent with the notion that the medial temporal region is vulnerable to brain perfusion deficits associated with HF, and provide evidence that such functional deficits may be specifically implicated in the pathophysiology of MDD associated with HF.

Background. There is increasing evidence that cognitive deficits are present in bipolar disorder (BP), but their neural correlates have not been fully explored. The aim of this study is to correlate structural brain abnormalities with cognitive performance in BP and to explore differences between clinical subtypes.

Method. Thirty-six BP patients (13 men, 23 women) with a mean age of 39 years (range 21–63 years) underwent neuropsychological testing and imaging. Twenty-five patients had bipolar disorder I (BP I) and 11 had bipolar disorder II (BP II). Patients with co-morbid psychiatric diagnosis, drug and alcohol abuse or systemic illness were excluded. Correlations between cognitive performance and structural brain changes were explored using high-resolution anatomical imaging and magnetization transfer imaging (MTI).

Results. In the whole BP group the difference between estimated pre-morbid IQ and current IQ was significantly correlated with left-sided reduction of the magnetization transfer ratio (MTR) in the superior temporal gyrus, uncus and para-hippocampal gyrus. In BP II patients the areas where these correlations were significant extended to the right superior and middle temporal gyri, cingulate gyrus, pre-cuneus and adjacent frontal and parietal white matter. The volume of superior temporal white matter was also correlated with IQ difference in this subgroup.

Conclusions. The study highlights the association between fronto-temporal abnormalities and decline in IQ in BP. The more extensive abnormalities present in BP II patients suggest that persistent depression, rather than mania, may be a key pathophysiological factor or that BP II represents a clinical phenotype with a higher risk of developing cognitive abnormalities.

Background. Previous work suggests that subthreshold depression and subthreshold (hypo)mania are common, although little is known about the prognosis in terms of transition to clinical disorder. This paper presents data on the temporal relationship between subthreshold and clinical expression of mood phenotypes.

Method. In a random general population sample of 7076 individuals, symptoms of depression and (hypo)mania were measured with the Composite International Diagnostic Interview (CIDI) at baseline, after 1 year, and 2 years later.

Results. At baseline, the lifetime prevalences of depressive and (hypo)manic symptoms were 17·2% and 1·2% respectively. Predictive values of mood symptoms for a DSM-III-R mood disorder ranged from 14·3% to 50%. (Hypo)manic mood symptoms had much higher predictive values than unipolar manifestations, not only for bipolar disorder but also for major depression.

Conclusions. The subthreshold expressions of depression and (hypo)mania are prevalent and continuous with more severe clinical states. The cross-prediction of mood symptoms may support a continuum from depressive to (hypo)manic symptoms. The high predictive value of (hypo)manic symptoms for mood disorders suggests that the experience of (hypo)manic symptoms is a stronger indicator of vulnerability for mood dysregulation than the experience of depressive symptoms.

Background. Depression is usually the predominant affective state in bipolar disorder. There are few studies, with discrepant views, examining the extent of cognitive impairment in patients with bipolar depression. To our knowledge, there are no previous studies examining decision-making ability or whether there is an affective attentional bias in bipolar depression.

Method. We ascertained 24 depressed bipolar I patients from acute psychiatric hospital wards and out-patient clinics and 26 age- and IQ-matched healthy controls. Using computerized tests we evaluated their performance on ‘neutral’ (non-emotional) cognitive tasks (i.e. memory, attention and executive function) and on novel tasks of emotional cognition (i.e. the decision-making task and the affective go/no-go task).

Results. Accuracy measures were significantly impaired on tests of visual and spatial recognition and attentional set-shifting in bipolar depression compared with age- and IQ-matched controls. The quality of decision-making was also significantly impaired in the patients. A mood-congruent attentional bias for ‘sad’ targets was not evident on the affective go/no-go task.

Conclusions. We found widespread evidence of significant cognitive impairment and impaired quality of decision-making in symptomatically severe depressed bipolar patients. This cognitive impairment may contribute to difficulties with daily living, decision-making and the ability to engage and comply with psychological and drug treatments.

Background. Recognition can be normalized in schizophrenia by providing patients with semantic organizational strategies through a levels-of-processing (LOP) framework. However, patients may rely primarily on familiarity effects, making recognition less sensitive than source monitoring to the strength of the episodic memory trace. The current study investigates whether providing semantic organizational strategies can also normalize patients' internal source-monitoring performance.

Method. Sixteen clinically stable medicated patients with schizophrenia and 15 demographically matched healthy controls were asked to identify the source of remembered words following an LOP-encoding paradigm in which they alternated between processing words on a ‘shallow’ perceptual versus a ‘deep’ semantic level. A multinomial analysis provided orthogonal measures of item recognition and source discrimination, and bootstrapping generated variance to allow for parametric analyses. LOP and group effects were tested by contrasting recognition and source-monitoring parameters for words that had been encoded during deep versus shallow processing conditions.

Results. As in a previous study there were no group differences in LOP effects on recognition performance, with patients and controls benefiting equally from deep versus shallow processing. Although there were no group differences in internal source monitoring, only controls had significantly better performance for words processed during the deep encoding condition. Patient performance did not correlate with clinical symptoms or medication dose.

Conclusions. Providing a deep processing semantic encoding strategy significantly improved patients' recognition performance only. The lack of a significant LOP effect on internal source monitoring in patients may reflect subtle problems in the relational binding of semantic information that are independent of strategic memory processes.

Background. The evidence regarding the independent influence of duration of untreated psychosis (DUP) on rate and time to remission is far from unequivocal. The goal of the current study was to examine the role of predictors for rate and time to remission in first-episode psychosis (FEP).

Method. The differential effect of age, gender, age of onset, duration of untreated psychosis (DUP), duration of untreated illness (DUI), pre-morbid adjustment, co-morbid diagnosis of substance abuse and adherence to medication on the rate of and time to remission were estimated using a logistic and Poisson regression, and survival analysis respectively, in FEP patients.

Results. In a sample of 107 FEP patients 82·2% achieved remission over a period of 2 years after a mean of 10·3 weeks (range 1–72). Regression analysis, based on complete data on all variables of interest (n=80), showed status of remission to be positively influenced by better pre-morbid adjustment (RR 0·57, 95% CI 0·34–0·95, p<0·05), later age of onset (RR 1·09, 95% CI 1·05–1·13, p<0·0001), higher level of adherence to medication (RR 1·96, 95% CI 1·38–2·76, p<0·001) and shorter DUI (RR 0·99, 95% CI 0·997–0·999, p<0·005). Time to remission was influenced by age of onset (HR 1·04, 95% CI 1·00–1·08, p<0·04) and adherence to medication (HR 1·58, 95% CI 1·11–2·23, p<0·01).

Conclusions. Improving adherence to medication early in the course of treatment may be an important intervention to improve short-term outcome.

Background. Patients diagnosed with schizophrenia consistently demonstrate impairment in memory acquisition. However, no empirical consensus has been achieved on whether or not patients are more prone to produce false memories.

Method. A visual variant of the Deese–Roediger–McDermott (DRM) paradigm was administered to 35 schizophrenia patients and 34 healthy controls. Recognition and recognition confidence were later tested for studied and lure items. Strong contextual cues at recognition encouraged adoption of a gist-based retrieval strategy, which was predicted to elicit over-confidence in errors and increase the false memory rate in patients.

Results. Patients were significantly impaired on true item recognition but did not display more false memories than healthy subjects. As predicted from prior findings by our group, patients were more confident than controls for lure items, while being at the same time under-confident for studied items (reduced confidence gap).

Conclusions. Although patients did not produce more false memories than controls, such errors were made with higher confidence relative to controls. The decreased confidence gap in patients is thought to stem from a gist-based recollection strategy, whereby little evidence suffices to make a strong judgment.

Background. In order to improve the treatment of medication-resistant negative symptoms in schizophrenia, new interventions are needed. Neuropsychological considerations and older reports in the literature point towards a potential benefit of body-oriented psychological therapy (BPT). This is the first randomized controlled trial specifically designed to test the effectiveness of manualized BPT on negative symptoms in chronic schizophrenia.

Method. Out-patients with DSM-IV continuous schizophrenia were randomly allocated to either BPT (n=24) or supportive counseling (SC, n=21). Both therapies were administered in small groups in addition to treatment as usual (20 sessions over 10 weeks). Changes in negative symptom scores on the Positive and Negative Symptom Scale (PANSS) between baseline, post-treatment and 4-month follow-up were taken as primary outcome criteria in an intention-to-treat analysis.

Results. Patients receiving BPT attended more sessions and had significantly lower negative symptom scores after treatment (PANSS negative, blunted affect, motor retardation). The differences held true at 4-month follow-up. Other aspects of psychopathology and subjective quality of life did not change significantly in either group. Treatment satisfaction and ratings of the therapeutic relationship were similar in both groups.

Conclusions. BPT may be an effective treatment for negative symptoms in patients with chronic schizophrenia. The findings should merit further trials with larger sample sizes and detailed studies to explore the therapeutic mechanisms involved.

Background. Some doctors who initially choose psychiatry do not pursue it as a long-term career. The study seeks to identify reasons for leaving psychiatry.

Method. Postal questionnaire survey of UK medical graduates of 1988, 1993, 1996 and 1999 identified as having left psychiatry; for comparison, doctors who left general practice or trauma and orthopaedics.

Results. Response rate was 74% (572/778); 488 respondents satisfied study criteria (59 psychiatry, 318 general practice, 111 trauma and orthopaedics). The speciality's poor public image, perceived lack of respect from medical peers, perceived threat of violence from patients, under-resourcing and low morale were problems for psychiatry leavers. Job stress, self-assessed unsuitability, and concerns about the lack of evidence-based treatments also influenced decisions to leave psychiatry.

Conclusions. Early exposure to psychiatry may help trainees assess their suitability. Negative perceptions of workforce issues (e.g. low morale) and of clinical issues (e.g. perceived lack of ability to improve prognosis) need addressing to increase retention.

Background. Spousal concordance for common mental disorders provides evidence of the relevance of social contextual factors. There are, however, limitations within the existing literature examining spousal similarity in mental health and little consensus as to the causes of spousal similarity. This study considers a large representative sample and examines an extensive range of risk factors using multilevel statistical methods to explore spousal similarity in common mental disorders.

Method. Data were from the Household, Income and Labour Dynamics in Australia (HILDA) Survey, a large nationally representative survey of Australian households. Analysis focused on 3808 mixed-sex couples in marriage and de facto relationships. Multilevel models assessed the mental health scale of the SF-36. Analyses considered risk factors at the individual, couple and area levels, examined the effects of relationship duration on concordance, and considered longitudinal data to assess the consistency with cross-sectional analysis.

Results. Significant spousal concordance on the mental health scale was demonstrated (r=0·25) and was independent of, and unexplained by mental health risk factors, including experience of multiple shared life events. Spousal similarity for mental health increased across the first 5 years of relationships.

Conclusions. Evidence of spousal concordance for common mental disorders highlights the importance of the social context of marriage in the aetiology of mental illness and identifies an important direction for further research.

Background. Prior research indicates that conduct disorder (CD) is associated with a range of co-morbid mental disorders. However, the actual prevalence, subtypes and patterns of co-morbidity of DSM-IV-defined CD in the general US population remains unknown.

Method. Retrospective assessment of CD and other DSM-IV disorders was conducted using fully structured diagnostic interviews among a nationally representative sample of respondents (n=3199) in the National Comorbidity Survey Replication (NCS-R).

Results. The estimated lifetime prevalence of CD in the US is 9·5% (12·0% among males and 7·1% among females), with a median age-of-onset of 11·6 (0·2) years. Latent class analysis (LCA) identified five CD subtypes characterized by rule violations, deceit/theft, aggression, severe covert behaviors, and pervasive CD symptoms. A dose–response relationship was revealed between CD subtype severity and risk of subsequent disorders. Results also indicated that CD typically precedes mood and substance use disorders, but most often occurs after impulse control and anxiety disorders. Although both active and remitted CD is associated with increased risk of the subsequent first onset of other mental disorders, remitted CD is associated with significantly lower risk of subsequent disorders.

Conclusions. CD is prevalent and heterogeneous in the US population, and more severe subtypes and the presence of active CD are associated with higher risk of co-morbid disorders. Future prospective studies using general population samples will further inform the nature and course of this disorder.

Background. There are no published criteria for improving the quality of effectiveness of randomized controlled trials (RCTs) in psychiatry.

Method. The authors review and systematize the relevant literature on effectiveness trials, with particular reference to psychiatry.

Results. In planning effectiveness RCTs in psychiatry, seven sets of issues need to be carefully considered: (i) study question (i.e. is the study question expressed in an answerable way?); (ii) reference population (i.e. what is the reference group or subgroup to which the trial results should be generalized?); (iii) patient sample (i.e. how far does the sample reflect the target population?); (iv) study settings (i.e. how representative are the study settings of routine clinical sites?); (v) study interventions (i.e. is the study intervention manualized, acceptable to patients and suitable for widespread use?); (vi) control condition (i.e. are the key characteristics of the control condition well described, and do they vary within and between sites?); and (vii) bias (e.g. attrition, blinding, concealment, consent and contamination).

Conclusions. More effectiveness trials are needed which have sufficient statistical power to provide precise answers to assist clinicians in making treatment decisions. The development of effectiveness trials in psychiatry, both for studies of individual treatments and for service evaluations, may be enhanced by carefully considering and justifying decisions in relation to each of the seven key headings proposed here.