This issue features a group of papers and a review article on the neuropsychology of attention deficit hyperactivity disorder (ADHD), groups of papers on schizophrenia, mental disorders in primary care, and affective disorders, and an additional paper by Dew et al. (pp. 1215–1227) regarding course of psychological distress over 4 years after heart transplantation.

Background. Several theoretical explanations of ADHD in children have focused on executive functioning as the main explanatory neuropsychological domain for the disorder. In order to establish if these theoretical accounts are supported by research data for adults with ADHD, we compared neuropsychological executive functioning and non-executive functioning between adults with ADHD and normal controls in a meta-analytic design.

Method. We compared 13 studies that (1) included at least one executive functioning measure, (2) compared the performance of an adult ADHD group with that of an adult normal control group, (3) provided sufficient information for calculation of effect sizes, and (4) used DSM-III-R or DSM-IV criteria to diagnose ADHD.

Results. We found medium effect sizes both in executive functioning areas [verbal fluency (d=0·62), inhibition (d=0·64 and d=0·89), and set shifting (d=0·65)] and in non-executive functioning domains [consistency of response (d=0·57), word reading (d=0·60) and color naming (d=0·62)].

Conclusions. Neuropsychological difficulties in adult ADHD may not be confined to executive functioning. The field is in urgent need of better-designed executive functioning tests, methodological improvements, and direct comparisons with multiple clinical groups to answer questions of specificity.

Background. Although children with hyperkinetic disorder and/or attention deficit hyperactivity disorder (ADHD) show disordered executive neuropsychological functioning, the nature of these changes remains controversial. Additionally, impairments in non-executive neuropsychological functioning have been relatively unexplored. Here, the authors describe the neuropsychological functioning of a sample of stimulant drug-naive boys with hyperkinetic disorder on a battery of neuropsychological tasks sensitive to impairments of both executive and non-executive functions.

Method. Seventy-five stimulant drug-naive boys meeting diagnostic criteria for ICD-10 hyperkinetic disorder were compared with 70 healthy developing controls matched for age but not IQ on computerized tests of neuropsychological functioning from the Cambridge Neuropsychological Test Automated Battery (CANTAB) and a Go/No-Go inhibition task.

Results. Boys with hyperkinetic disorder exhibited impairments on tasks with a prominent executive component – working memory, planning, strategy formation, attentional set-shifting and on a reaction time task. However, they were also impaired on tasks without prominent executive components – pattern and spatial recognition, spatial span, delayed matching to sample and paired associates learning. Contrary to predictions, no impairment was observed on the Go/No-Go inhibition task.

Conclusions. Medication-naive boys with hyperkinetic disorder displayed a broad range of neuropsychological impairments. Deficits were demonstrated on tasks with and without prominent executive components. Impairments were not confined to tasks dependent upon frontostriatal functioning, cannot wholly be explained by deficits in inhibitory control, nor can they be attributed to intelligence or previous exposure to stimulant medication.

Background. A limited number of studies have examined neuropsychological functioning in the family members of ADHD youth, and none have focused exclusively on relatives of females.

Method. Structured diagnostic interviews and neuropsychological batteries were administered to parents and siblings enrolled in a family study of girls with and without ADHD. Relatives were stratified into three groups: relatives of DSM-IV ADHD probands with ADHD (n=106), relatives of ADHD probands without ADHD (n=189) and relatives of controls without ADHD (n=243). Analyses were also conducted on a subgroup of families in which more than one member had ADHD.

Results. The neuropsychological battery as a whole distinguished affected and unaffected ADHD relatives from controls. The Wechsler Oral Arithmetic subtest, the Stroop Word, Color and Color-Word subscales were impaired in affected ADHD relatives, as were the WRAT-R Arithmetic and Reading subtests. Only the Stroop Color-Word and Interference subtests and the WRAT-R Arithmetic subtest showed significant impairments in unaffected relatives. In multiplex families, additional impairments were found in unaffected relatives on the Stroop Color subtest and the Wechsler Oral Arithmetic subtest. Analyses based on DSM-III-R diagnoses produced nearly identical results. Minor differences emerged across relatives of probands with different DSM-IV subtypes.

Conclusions. Data were consistent with our previous study of relatives of boys with ADHD. Neuropsychological impairments in relatives of female ADHD probands were primarily associated with the diagnosis of ADHD, but subtle cognitive impairments that index familial vulnerability to the disorder may exist.

Background. Research has documented high levels of co-morbidity among childhood externalizing disorders, but its etiology remains in dispute. Specifically, although all behavior genetic studies of the etiology of the co-occurrence of attention deficit-hyperactivity disorder (ADHD), oppositional defiant disorder (ODD), and conduct disorder (CD) agree that genetic factors are important, differences exist across studies in the relative weight assigned to genetic, shared environmental factors (i.e. factors that increase similarity among family members), and non-shared environmental factors (i.e. factors that decrease similarity among family members). Because heritability estimates can vary across informants, we used a biometric informant-effects model to determine whether these discrepancies were a function of systematic differences in maternal and child informant reports of ADHD, CD, and ODD.

Method. We studied 1782 11-year-old twins from the Minnesota Twin Family Study. Symptom counts for each disorder were obtained from interviews administered to twins and their mothers. We fit a model that allowed us to examine, both across and within informants, the genetic and environmental contributions to the co-occurrence among ADHD, CD, and ODD.

Results. The results revealed that the co-occurrence among the disorders common to maternal and child informant reports was influenced largely by shared environmental forces. Genetic factors also contributed, though their impact was only marginally significant. In contrast, the co-occurrence unique to each informant was influenced exclusively by either genetic or non-shared environmental factors.

Conclusions. Such findings offer additional evidence that shared environmental factors are important to the co-morbidity among ADHD, CD, and ODD, and highlight the necessity of considering informant effects when drawing conclusions about the origins of co-morbidity from analyses of genetically informative data.

Background. We assess claims that the documented rise in psychiatric morbidity during the nineteenth and twentieth centuries was associated with an increasing incidence of schizophrenia.

Method. Cross-sectional epidemiological comparison of the incidence of schizophrenia in one urban, industrialized community at three points over more than 100 years using new data from 1881–1902 and two pre-existing datasets, 1978–1980 and 1992–1994. For 1881–1902, 34 cases of schizophrenia were obtained through retrospective diagnosis, using Research Diagnostic Criteria, of a random 14·5% sample of first admissions to Nottingham Asylum (n=330). Inter-rater reliability and leakage analyses were performed. The administrative incidence for all three studies was directly standardized against 1991 census data. Local statistics on total psychiatric morbidity in Nottingham were taken from the asylum superintendent's register and recent data from the Office of National Statistics.

Results. Official local and national rates of total psychiatric morbidity increased exponentially. There was no significant change in the incidence of schizophrenia over the 114-year period 1881–1994.

Conclusions. The rise in both local and national official statistics of psychiatric morbidity 1881–1994 was not associated with a significant increase in the incidence of schizophrenia. Stability in the epidemiology of schizophrenia at a geographical level is found despite important demographic changes.

Background. Previous findings of increased rates of psychotic disorders among immigrants to Sweden are primarily based on hospital samples. The aim of the current study was to compare the risks of first contact for psychotic and schizophrenic disorders among first- and second-generation immigrants to the risks in native ‘Swedes’.

Method. During a 3-year period, diagnostic information was collected on all patients with a possible psychotic disorder who made a first-in-lifetime contact with both in-patient and out-patient psychiatric services in Malmö.

Results. First-generation immigrants to Sweden had an increased risk of developing psychotic and schizophrenic disorders compared to Swedes (age- and gender-adjusted relative risk, RR 2·9, 95% CI 2·0–4·0 and RR 4·0, 95% CI 1·8–8·6 respectively). Risks for these disorders were not significantly increased in second-generation immigrants. The highest risks of developing psychotic disorder compared to Swedes were found in first-generation immigrants with ‘black’ (versus ‘neither black nor white’, or ‘white’) skin colour (RR 5·8, 95% CI 2·8–13·4) and birthplace in a developing (versus developed) country (RR 3·3, 95% CI 2·3–4·8).

Conclusion. The increased risks of psychosis obtained especially in immigrant groups having relatively disadvantaged status in Sweden suggest that psychosocial factors may contribute to the development of psychotic disorders.

Background. Evidence has mounted that some patients with schizophrenia experience remission of symptoms and restoration of social and vocational functioning. The purpose of this study was to identify neurocognitive variables associated with recovery from schizophrenia.

Method. Twenty-eight patients diagnosed with DSM-IV schizophrenia or schizoaffective disorder and who met our operational definition of recovery from schizophrenia underwent a battery of neurocognitive tests. These subjects were matched with schizophrenia patients who did not meet recovery criteria (‘non-recovered’) and with normal controls.

Results. On tests of executive functioning, verbal fluency and verbal working memory, recovered subjects performed significantly better than non-recovered subjects and were comparable to normal controls. Patient groups did not differ on a test that assessed early visual processing, but both groups performed significantly worse than normal controls.

Conclusions. Three measures of frontal lobe functioning appear to be neurocognitive domains associated with recovery from schizophrenia. These findings help narrow the search for targets for cognitive remediation that may have implications for improving community functioning.

Background. Prevalence and co-occurrence of mental disorders is high among patients consulting their family general practitioner (GP) for a new health problem, but data on diagnostics and sociodemographics are sketchy.

Method. A cross-sectional two-phase epidemiological study. A total of 1785 consecutive patients with new complaints, aged 18–65 years, consulting 28 family practices during March–April 2000 in Aarhus County, Denmark were screened, in the waiting room, for mental and somatic symptoms with SCL-8 and SCL-Somatization questionnaires, for illness worry with Whitely-7 and for alcohol dependency with CAGE. In a stratified random sample of 701 patients, physician interviewers established ICD-10 diagnoses using the SCAN interview. Prevalence was calculated using weighted logistic regression, thus correcting for sample skewness.

Results. Half of the patients fulfilled criteria for an ICD-10 mental disorders and a third of these for more than one group of disorders. Women had higher prevalence of somatization disorder and overall mental disorders than men. Men had higher prevalence of alcohol abuse and hypochondriasis than women. Psychiatric morbidity tended to increase with age. Prevalence of somatoform disorders was 35·9% (95% CI 30·4–41·9), anxiety disorders 16·4% (95% CI 12·7–20·9), mood disorders 13·5% (95% CI 11·1–16·3), organic mental disorders 3·1% (95% CI 1·6–5·7) and alcohol abuse 2·2% (95% CI 1·5–3·1). Co-morbidities between these groups were highest for anxiety disorders, where 89% also had another mental diagnosis, and lowest for somatoform disorders with 39%.

Conclusions. ICD-10 mental disorders are very prevalent in primary care and there is a high co-occurrence between most disorders. Somatoform disorders, however, more often than not exist without other mental disorders.

Background. Depression is highly co-morbid with both psychiatric and chronic somatic disease. These types of co-morbidity have been shown to exert opposite effects on underdiagnosis of depression by general practitioners (GPs). However, past research has not addressed their combined effect on underdiagnosis of depression.

Method. Co-morbidity data on 191 depressed primary-care patients selected by a two-stage sampling procedure were analysed. Diagnoses of major depression and/or dysthymia in the last 12 months were assessed using a standardized psychiatric interview (CIDI) and compared with depression diagnoses registered by GPs in patient contacts during the same period. Presence of psychiatric and chronic somatic co-morbidity was determined using the CIDI and contact registration, respectively.

Results. Regression analysis showed a significant interaction effect between psychiatric and chronic somatic co-morbidity on GPs’ diagnosis of depression, while taking into account the effects of sociodemographic variables, depression severity and number of GP contacts. Subsequent stratified analysis revealed that in patients without chronic somatic co-morbidity, a lower educational level, a less severe depression, and fewer GP contacts all significantly increased the likelihood of not being diagnosed as depressed. In contrast, in patients with chronic somatic co-morbidity, only having no psychiatric co-morbidity significantly decreased the likelihood of receiving a depression diagnosis.

Conclusions. Our results indicate that the effects of psychiatric co-morbidity and other factors on underdiagnosis of depression by GPs differ between depressed patients with and without chronic somatic co-morbidity. Efforts to improve depression diagnosis by GPs seem to require different strategies for depressed patients with and without chronic somatic co-morbidity.

Background. Acts of suicide differ widely in the amount of planning preceding the act. Correlates of completed suicide in China identified in a previous investigation were re-examined to identify those that may be especially relevant to low-planned (impulsive) and high-planned suicidal behavior. The association of planning and method in completed suicide was also assessed.

Method. A psychological autopsy study of 505 suicide decedents aged [ges ]18 years sampled to be representative of suicides in China was conducted. Multinomial regression analyses compared three levels of suicide planning (low, intermediate, high).

Results. Women and younger individuals were more likely to carry out low-planned and intermediate-planned than high-planned acts of suicide. Greater acute stress distinguished low-planned from high-planned suicides. Ingestion of pesticides stored in the home was a more commonly employed method in low-planned than high-planned suicides.

Conclusions. Low-planned suicides are more common in women, in younger individuals, and among those who are experiencing acute stress. Prevention strategies targeted at restricting access to pesticides may preferentially lower the rate of low-planned suicides.

Background. There is increasing evidence that attitudes and beliefs are important in predicting adherence to treatment and medication in depressive and bipolar disorders. However, these attitudes have received little study in patients whose disorders were sufficiently severe to require hospitalization.

Method. The Antidepressant Compliance Questionnaire (ADCQ) was mailed to a large population of patients with depressive or bipolar disorder, representative of patients treated in hospital settings in Denmark.

Results. Of the 1005 recipients, 49·9% responded to the letter. A large proportion of the patients (40–80%) had erroneous views as to the effect of antidepressants. Older patients (over 40 years of age) consistently had a more negative view of the doctor-patient relationship, more erroneous ideas concerning the effect of antidepressants and a more negative view of antidepressants in general. Moreover, their partners agreed on these negative views. Women had a more negative view of the doctor-patient relationship than men, and patients with a depressive disorder had a more negative view of antidepressants than patients with bipolar disorder. The number of psychiatric hospitalizations or the type of treating physician (general practitioner, psychiatrist in private practice, community psychiatrist, hospital psychiatrist, other doctor) did not affect attitudes and beliefs.

Conclusion. Lack of knowledge about affective disorder and its treatment and a critical attitude, especially among older patients, may add to an adverse prognosis of depressive and bipolar disorders.

Background. Like individuals exposed to other life stressors, patients undergoing organ transplantation typically show elevated psychological distress initially post-transplant, with improvement thereafter. However, this ‘average’ pattern may conceal subgroups with differing profiles of psychological response. We sought to identify unique temporal distress profiles, and their predictors, after heart transplantation.

Method. A total of 156 transplant recipients (refusal rate, 6%) were enrolled and assessed at 2, 7, 12, 36, and 42 months post-transplant. Cluster analysis was used to identify distinct distress profiles over time. Multivariate analyses examined health and psychosocial predictors of the profiles.

Results. Five groups were identified, with either: (a) low distress at all time-points (45% of the sample), (b) high, clinically significant distress at all times (21%), (c) high distress over several years with low distress only at final assessment (12%), (d) high distress during the first several months with decline thereafter (6%), or (e) fluctuating distress levels (16%). Patients showing any distress (versus none) were more likely to have a pre-transplant psychiatric history, poorer social supports and more physical impairment early post-transplant, and continued physical impairment over time. Among distressed patients, those with persistent (versus declining) distress were most likely to be female, waited more briefly for transplant, and were most physically impaired early post-transplant. While persistently distressed patients had better social supports early post-transplant, these supports subsequently worsened.

Conclusions. Individuals differ in whether and when psychological distress abates after heart transplantation. Findings regarding distress profiles and their predictors may inform the design of interventions to address each transplant recipient's unique psychological needs.