This issue features groups of papers on bipolar disorder, neuropsychology and psychophysiology of psychiatric disorders, epidemiology, and relationships of adolescent disorders to parental psychopathology.

Background. The aim was to systematically integrate the available evidence on psychosocial and demographic factors associated with response prediction to prophylactic lithium.

Method. Each psychosocial or demographic variable that was related to lithium response in at least one study was examined with respect to response prediction. If several studies were located for the same variable results were integrated using a meta-analytical approach. To account for heterogeneity of primary studies aggregation of results was based on a random-effects model.

Results. Out of 27 psychosocial and demographic variables investigated in this review, nine variables were identified as significantly related to outcome under to prophylactic lithium: (1) high social status, (2) social support, (3) good compliance, and (4) dominance may be protective against a recurrence under lithium. In contrast, (5) stress, (6) high expressed emotions, (7) neurotic personality traits, (8) unemployment, and (9) a high number of life events were identified as possible risk factors for poor response.

Conclusions. This systematic review shows a surprisingly high number of psychosocial variables to be related to lithium response. Effect sizes were, however, small to moderate. Many variables should, therefore, be considered simultaneously to predict response.

Background. Despite increasing adoption of clinical practice guidelines in psychiatry, there is little measurement of provider implementation of these recommendations, and the resulting impact on clinical outcomes. The current study describes one effort to measure these relationships in a cohort of public sector out-patients with bipolar disorder.

Method. Participants were enrolled in the algorithm intervention of the Texas Medication Algorithm Project (TMAP). Study methods and the adherence scoring algorithm have been described elsewhere. The current paper addresses the relationships between patient characteristics, provider experience with the algorithm, provider adherence, and clinical outcomes. Measurement of provider adherence includes evaluation of visit frequency, medication choice and dosing, and response to patient symptoms. An exploratory composite ‘adherence by visit’ score was developed for these analyses.

Results. A total of 1948 visits from 141 subjects were evaluated, and utilized a two-stage declining effects model. Providers with more experience using the algorithm tended to adhere less to treatment recommendations. Few patient factors significantly impacted provider adherence. Increased adherence to algorithm recommendations was associated with larger decreases in overall psychiatric symptoms and depressive symptoms over time, but did not impact either immediate or long-term reductions in manic symptoms.

Conclusions. Greater provider adherence to treatment guideline recommendations was associated with greater reductions in depressive symptoms and overall psychiatric symptoms over time. Additional research is needed to refine measurement and to further clarify these relationships.

Background. The frequency and clinical, neuropsychological and neuroimaging correlates of apathy in patients who have had a stroke are inadequately defined.

Method. A total of 167 consecutive patients admitted to the stroke units of two university hospitals after an ischaemic stroke and 109 controls received extensive medical, psychiatric and neuropsychological assessments; a subset received a magnetic resonance imaging (MRI) scan. The groups were matched for sex and age. Patients were assessed 3–6 months after their stroke. The sample for this study comprised 135 patients and 92 controls who completed the Apathy Evaluation Scale (AES).

Results. Apathy was present in 26·7% of stroke patients compared to 5·4% of controls. Apathetic stroke patients were older, more functionally dependent and had lower Mini-Mental State Examination (MMSE) scores than those without apathy. Apathy was not associated with risk factors for cerebrovascular disease or stroke severity. There was a weak but significant correlation between apathy and self-reported depression but not with clinician-rated depression. Neuropsychologically, after correction for age, premorbid intelligence (IQ) and depression, apathy was associated with reduced attention and speed of information processing. On neuroimaging there were trends for associations of apathy with the extent of hyperintensities in the right hemisphere and right fronto-subcortical circuit, but not with total stroke volume or number of strokes.

Conclusions. Apathy is common following a cerebrovascular event. Presence of apathy may be related to older age and right fronto-subcortical pathway pathology, rather than stroke severity. It is associated with functional impairment and cognitive deficits.

Background. This study examined the relationship between internal source monitoring and disordered speech in patients with schizophrenia or schizoaffective disorder. It was predicted that internal source monitoring would relate specifically to one type of communication disturbance, the missing information reference.

Method. Immediate, working, and internal source memory were assessed in 47 out-patients diagnosed with schizophrenia or schizoaffective disorder. Speech samples were also collected from this sample and coded for six types of communication disturbance.

Results. Of the six types of communication disturbance coded in this study, internal source monitoring indices were uniquely related to the frequency of the missing information reference. Furthermore, internal source monitoring was the only type of short-term memory process assessed in this study that was related to the missing information reference. Neither immediate nor working-memory capacity was related significantly to the frequency of this type of communication disturbance.

Conclusions. This study adds to our knowledge of the neurocognitive processes that underlie communication disturbance in the speech of patients with schizophrenia.

Background. Saccadic distractibility, as measured by the antisaccade task, has attracted attention as a putative endophenotypic marker for schizophrenia. Some studies have suggested that this measure is elevated in the unaffected relatives of schizophrenia patients. However, recent studies have called this into question and the topic remains controversial.

Method. Saccadic distractibility was measured in 53 patients with DSM-IV schizophrenia, 80 unaffected first-degree relatives and 41 unaffected controls.

Results. Schizophrenia patients performed worse than relatives and controls combined (p<0·00001), but relatives did not differ significantly from controls. Performance in multiply affected families was no worse than that in singly affected families. Relatives with a high presumed genetic risk for schizophrenia performed no worse than other relatives. The performance of the patients did not predict that of their relatives.

Conclusions. These results demonstrate that saccadic distractibility is strongly associated with disease status but not with genetic loading for schizophrenia. We conclude that saccadic distractibility is unlikely to be useful as an endophenotypic marker in schizophrenia.

Background. Deficits in prepulse inhibition (PPI) of the acoustic startle response have been suggested as a potentially useful endophenotype for schizophrenia spectrum disorders and may explain certain symptoms and cognitive deficits observed in the psychoses. PPI deficits have also been found in mania, but it remains to be confirmed whether this dysfunction is present in the euthymic phase of bipolar disorder.

Method. Twenty-three adult patients with DSM-IV bipolar disorder were compared to 20 controls on tests of acoustic startle reactivity and PPI of the startle response. Sociodemographic and treatment variables were recorded and symptom scores assessed using the Hamilton Depression Inventory and the Young Mania Rating Scale.

Results. Overall, the patient and control groups demonstrated similar levels of startle reactivity and PPI, although there was a trend for the inter-stimulus interval to differentially affect levels of PPI in the two groups.

Conclusions. In contrast to bipolar patients experiencing a manic episode, general levels of PPI were normal in this euthymic sample. Further studies are required to confirm this finding and to determine the mechanisms by which this potential disruption/normalization occurs. It is suggested that an examination of PPI in a high-risk group is required to fully discount dysfunctional PPI as a potentially useful endophenotype for bipolar disorder.

Background. This study addressed the prevalences, correlates, co-morbidity and disability of DSM-IV generalized anxiety disorder (GAD) and other psychiatric disorders in a large national survey of the general population, the National Institute on Alcohol Abuse and Alcoholism's (NIAAA) National Epidemiologic Survey on Alcohol and Related Conditions (NESARC). The study presents nationally representative data, for the first time, on prevalence, correlates, co-morbidity, and comparative disability of DSM-IV GAD.

Method. Data are taken from a large (n=43093) representative sample of the adult USA population.

Results. Prevalences of 12-month and lifetime GAD were 2·1% and 4·1%. Being female, middle-aged, widowed/separated/divorced, and low income increased risk, while being Asian, Hispanic, or Black decreased risk. GAD was highly co-morbid with substance use, and other anxiety, mood, and personality disorders. Co-morbidity in GAD was not substantially greater than for most other Axis I and II disorders. Disability and impairment in pure GAD were equivalent to pure mood disorders, but significantly greater than in pure substance use, and other anxiety and personality disorders. Individuals co-morbid for GAD and each mood disorder were more disabled than those with pure forms of GAD or each mood disorder. When co-morbid with GAD, nicotine dependence and other anxiety and personality disorders were not associated with increased disability over that associated with pure GAD, but GAD did show increased disability over that due to each of these disorders in pure form.

Conclusions. Associations between GAD and Axis I and II disorders were strong and significant, with variation among specific disorders. Results strongly support GAD as an independent disorder with significant impairment and disability.

Background. Excessive worry is required by DSM-IV, but not ICD-10, for a diagnosis of generalized anxiety disorder (GAD). No large-scale epidemiological study has ever examined the implications of this requirement for estimates of prevalence, severity, or correlates of GAD.

Method. Data were analyzed from the US National Comorbidity Survey Replication, a nationally representative, face-to-face survey of adults in the USA household population that was fielded in 2001–2003. DSM-IV GAD was assessed with Version 3.0 of the WHO Composite International Diagnostic Interview. Non-excessive worriers meeting all other DSM-IV criteria for GAD were compared with respondents who met full GAD criteria as well as with other survey respondents to consider the implications of removing the excessiveness requirement.

Results. The estimated lifetime prevalence of GAD increases by ~40% when the excessiveness requirement is removed. Excessive GAD begins earlier in life, has a more chronic course, and is associated with greater symptom severity and psychiatric co-morbidity than non-excessive GAD. However, non-excessive cases nonetheless evidence substantial persistence and impairment of GAD, high rates of treatment-seeking, and significantly elevated co-morbidity compared with respondents without GAD. Non-excessive cases also have sociodemographic characteristics and familial aggregation of GAD comparable to excessive cases.

Conclusions. Individuals who meet all criteria for GAD other than excessiveness have a somewhat milder presentation than those with excessive worry, yet resemble excessive worriers in a number of important ways. These findings challenge the validity of the excessiveness requirement and highlight the need for further research into the optimal definition of GAD.

Background. This paper describes the 12-month prevalence, severity and demographic correlates of 16 DSM-IV psychiatric disorders and service utilization in the Mexican urban population aged 18–65 years of age. This is representative of 75% of the national adult population.

Method. The sample design was a strict probability selection scheme. The response rate was 76·6%. The World Mental Health Survey version of the Composite International Diagnostic Interview was installed on laptops and administered by lay interviewers. An international WHO task force carried out its translation into Spanish.

Results. The 12-month prevalence of any disorder was 12·1%. The most common disorders were specific phobia (4·0%), major depressive disorder (3·7%) and alcohol abuse or dependence (2·2%). The 12-month prevalence of very severe disorders was 3·7% of which only 24% used any services. Age was the only variable associated with any 12-month disorder, with the younger more likely to report any disorder. Income was associated with severity, with low and low–average incomes more likely to report a 12-month disorder. Females were more likely to report a mood and anxiety disorder, but less likely to report a substance disorder. The group of separated/widowed/divorced was more likely to report a mood and an impulse-control disorder.

Conclusions. The results show that while psychiatric disorders are common in the Mexican population, very severe mental disorders are less common and there is extreme under-utilization of mental health services.

Background. Empirical findings suggest that psychiatric illness is associated with cardiovascular disease (CVD). The purpose of this study was to compare the strength of the association of lifetime post-traumatic stress disorder (PTSD) and lifetime major depression on CVD among Northern Plains American Indians.

Method. A total of 1414 participants aged 18–57 years completed a structured interview that assessed psychiatric diagnoses, alcohol abuse/dependence, self-reported CVD, and traditional CVD risk factors including age, sex, education, diabetes, high blood pressure, and smoking. Logistic regression analyses compared the odds ratios of CVD in participants with and without diagnosed PTSD or major depression.

Results. The rates of lifetime PTSD and major depression were 15% and 8% respectively. CVD was more commonly reported by participants with PTSD than by those without PTSD (12% v. 5%, p[les ]0·01). Likewise, more participants with major depression reported CVD than did their non-depressed counterparts (14% v. 6%, p[les ]0·05). PTSD was significantly associated with CVD even after controlling for traditional CVD risk factors and major depression (odds ratio 2·0, confidence interval 1·1–3·8). In contrast, the association of major depression with CVD was not significant after accounting for both traditional risk factors and PTSD.

Conclusions. Rates of PTSD are high in American Indian communities. Rising CVD rates in this population may be better understood if PTSD is considered along with other traditional risk factors. Future research should examine the association and mechanisms of PTSD and CVD prospectively. Such data could lead to more effective CVD prevention efforts for American Indians.

Background. The aim of this study was to explore the relationship between risk of psychosis, common mental disorder (CMD) and indicators of racism among ethnic minority groups in England and how this relationship may vary by particular ethnic groups.

Method. A multivariate analysis was carried out of quantitative, cross-sectional data from a nationally representative community sample of people aged between 16 and 74 years from the largest ethnic minority groups in England: those of Caribbean, Indian, Pakistani, Bangladeshi and Irish origin.

Results. Experience of interpersonal racism and perceiving racism in the wider society each have independent effects on the risk of CMD and psychosis, after controlling for the effects of gender, age and socio-economic status. There was some variation in the findings when they were conducted for separate ethnic and gender groups.

Conclusions. An understanding of the relationship between racism and mental health may go some way towards explaining the ethnic variations found in both CMD and, particularly, psychosis.

Background. Studies about the effect of time on the degree of psychological distress among immigrants have reported conflicting findings. We investigated this issue in Israel, which supports actively the absorption of immigrants, and also looked for risk and protective factors for psychological distress 5 years post-immigration.

Method. A nationwide sample of 600 subjects who emigrated from the former Soviet Union to Israel in 1990 were interviewed in 1995, with the demoralization subscale of the Psychiatric Epidemiologic Research Interview (PERI-D) for psychological distress, and with a series of questions regarding sociodemographic characteristics, personal assets and their absorption experience. The results were compared with those obtained in a previous study for a sample of the same cohort of immigrants in their first year post-immigration. A multivariate analysis was carried out to examine the relation between the PERI score and the different independent variables.

Results. Although, 5 years after immigration, a favorable change in objective parameters of absorption was found, no decrease in psychological distress was observed. The main risk factors remaining significantly associated with psychological distress in the final model were: adverse life events, lack of perceived social support, poor family functioning, external locus of control, poor physical health status, non-identification with host society and, to a lesser degree, poor material conditions.

Conclusion. Psychological readjustment apparently takes longer than other processes of adaptation. Several years after immigration, social and psychological factors have a more important role for the well-being of immigrants than their material conditions.

Background. Although parents with psychiatric disorders are likely to have children with psychiatric problems, the nature of disorder risk to offspring of antisocial parents has received limited attention.

Method. We examined the prevalence of common externalizing and internalizing disorders in the pre-adolescent and late adolescent offspring of antisocial parents. Lifetime diagnoses for a sample of 11-year-old twins (958 males, 1042 females) and a sample of 17-year-old twins (1332 males, 1434 females), as well as their parents, were obtained through in-person interviews. Odds ratios were calculated for the effect of the parent's diagnosis on the child's diagnosis, controlling for the effect of the co-parent's diagnosis.

Results. We found that parental antisociality places the child at increased risk for developing a range of externalizing and internalizing disorders. This increase is evident by pre-adolescence and extends to a wide range of disorders by late adolescence. Each parent has an effect net any effects of the co-parent.

Conclusions. Antisocial parents have children who have an increased likelihood of developing a broad range of psychiatric disorders.

Background. We investigated the links between familial loading, preadolescent temperament, and internalizing and externalizing problems in adolescence, hereby distinguishing effects on maladjustment in general versus dimension-specific effects on either internalizing or externalizing problems.

Method. In a population-based sample of 2230 preadolescents (10–11 years) familial loading (parental lifetime psychopathology) and offspring temperament were assessed at baseline by parent report, and offspring psychopathology at 2·5-years follow-up by self-report, teacher report and parent report. We used purified measures of temperament and psychopathology and partialled out shared variance between internalizing and externalizing problems.

Results. Familial loading of internalizing psychopathology predicted offspring internalizing but not externalizing problems, whereas familial loading of externalizing psychopathology predicted offspring externalizing but not internalizing problems. Both familial loadings were associated with Frustration, low Effortful Control, and Fear. Frustration acted as a general risk factor predicting severity of maladjustment; low Effortful Control and Fear acted as dimension-specific risk factors that predicted a particular type of psychopathology; whereas Shyness, High-Intensity Pleasure, and Affiliation acted as direction markers that steered the conditional probability of internalizing versus externalizing problems, in the event of maladjustment. Temperament traits mediated one-third of the association between familial loading and psychopathology. Findings were robust across different composite measures of psychopathology, and applied to girls as well as boys.

Conclusions. With regard to familial loading and temperament, it is important to distinguish general risk factors (Frustration) from dimension-specific risk factors (familial loadings, Effortful Control, Fear), and direction markers that act as pathoplastic factors (Shyness, High-Intensity Pleasure, Affiliation) from both types of risk factors. About one-third of familial loading effects on psychopathology in early adolescence are mediated by temperament.