Background. The reform of mental health services needs to be guided by an overall conceptual framework. Such a framework is important to avoid many risks, including extrapolating from a specific service site to other services, without taking into account local and regional variables.

Methods. A conceptual framework, the ‘matrix model’, is proposed. This model has been developed using the most relevant information that is necessary for describing and interpreting mental health services data as well as patient-based information.

Results. The ‘matrix model’ has two dimensions: the geographical, which refers to three levels (country, local and patient) and the temporal, which refers to three phases (inputs, processes and outcomes). Using these two dimensions a nine-cell matrix is constructed to bring into focus critical issues for mental health services. The relevance of each level and each phase is briefly presented.

Conclusions. The matrix is intended to assist clinicians, planners and researchers to deal with clinical phenomena, organizational issues, and research questions that share a degree of complexity that render inadequate analyses and the interventions made only at one level. The matrix model applies particularly to mental health systems of care that are provided with a public health framework, and is less useful for contexts that consist of clinicians offering only one-to-one treatments, within fragmented programmes of care.

Background. The purpose of this analysis was to examine: (1) the prevalence of psychiatric disorders among disabled people, using seven different measures of disability; (2) variation in disability between and within psychiatric diagnostic categories; and (3) relationship of diagnosis and disability to health service utilization.

Method. Data were drawn from Phase I and Phase II of the Eastern Baltimore Mental Health Survey, part of the Epidemiologic Catchment Area Program (ECA) conducted in 1980–1 to survey mental morbidity within the adult population. A total of 810 individuals received both a household interview and a standardized clinical psychiatric evaluation. Estimated prevalence rates were computed using appropriate survey sampling weights.

Results. Prevalence of disability ranged from 2·5 to 19·5%, varying with specific disability measure. Among those classified as disabled by any of the measures examined, 56 to 92% had a psychiatric disorder and serious chronic medical conditions were present in the majority of these cases (54 to 78%). Disability was expressed differently among the various diagnostic groups. Diagnostic category and disability were significant independent predictors of medical service utilization and receipt of disability payments.

Conclusions. The majority of disabled adults living in the community have diagnosable psychiatric disorders, with the majority of these individuals suffering from significant chronic medical conditions as well, thus making co-morbidity the norm.

Background. Elderly residents of public housing have high rates of psychiatric disorders, but most of those in need of care do not use any mental health service. This study examines the use of formal and alternative informal sources of mental health care in a sample of elderly African-American public-housing residents.

Method. Data from an epidemiological survey of six Baltimore public-housing developments for the elderly (weighted N=818) were analysed to examine the utilization of mental health services by older African-American residents. Logistic regression analyses were used to determine correlates of using formal and informal sources by those needing mental health care.

Results. Thirty-five per cent of subjects needed mental health care. Less than half (47%) of those in need received any mental health care in the previous 6 months. Residents in need were more likely to use formal (38·5%) than informal sources (18·6%) for care. The strongest correlates of using formal providers were substance use disorder (OR=15·62), Medicare insurance (OR=10·31) and psychological distress (OR=10·27). The strongest correlates of using informal sources were perceiving little or no support from religious/spiritual beliefs (OR=21·65), cognitive disorder (OR=19·71) and having a confidant (OR=15·07).

Conclusions. Contrary to elderly African-Americans in general, those in public housing rely more on formal than informal sources for mental health problems. Nevertheless, both sources fail to fill the gap between need and met need. Interventions to increase identification, referral and treatment of elderly public-housing residents in need should target general medical providers and clergy and include assertive outreach by mental health specialists.

Background. The methodology for measuring the needs of patients with severe mental illness is now well established through the MRC Needs for Care Assessment Schedule and its modification in the form of the Cardinal Needs Assessment. This paper reports the rationale and construction of a relatives' version of the Cardinal Needs Schedule and looks at preliminary data reporting on reliability and validity.

Methods. Potential problem areas for relatives were identified from the literature. The criteria determining Cardinal Needs for each problem included objective threshold, carer concern, and carer cooperation. The reliability of the Schedule was assessed in a study whereby 27 relatives of patients with established schizophrenic illness completed two Schedules administered by two independent raters within a short time period.

Results. The Schedule was acceptably reliable for most areas of need although there were some difficulties associated with the cooperation criteria. Concurrent measures of relatives and patients including EE, relative distress and patient psychopathology indicated that the Relatives' Cardinal Needs Schedule shows acceptable validity when used with a sample of 45 relatives.

Conclusions. The paper suggests that the Schedule may prove to be a useful tool for both clinicians and researchers interested in establishing and evaluating family interventions.

Background. Staff and severely mentally ill patients differ in their assessments of need. This study compares staff and patient assessments of need for people suffering from psychotic disorders.

Method. The needs of an epidemiologically representative sample of 137 patients from a catchment area psychiatric service in South London who had an ICD-10 diagnosis of a functional psychotic disorder were assessed cross-sectionally by patients and staff, using the Camberwell Assessment of Need.

Results. Staff rated patients to have on average 6·1 needs, and patients rated 6·7 needs (t=2·58, df=136, P=0·011). This difference was accounted for by the staff rating of 1·2 unmet needs and the patient rating of 1·8 unmet needs (t=3·58, df=136, P<0·001). There was no difference in rating of total number of met needs. There was no difference in ratings in relation to any patient sociodemographic characteristics. There was moderate or better agreement on the presence of a need for 13 of the 22 domains in the Camberwell Assessment of Need.

Conclusions. Staff and patients moderately agree about met needs, but agree less often on unmet needs.

Background. The paper reports on the development of the WHOQOL-BREF, an abbreviated version of the WHOQOL-100 quality of life assessment.

Method. The WHOQOL-BREF was derived from data collected using the WHOQOL-100. It produces scores for four domains related to quality of life: physical health, psychological, social relationships and environment. It also includes one facet on overall quality of life and general health.

Results. Domain scores produced by the WHOQOL-BREF correlate highly (0·89 or above) with WHOQOL-100 domain scores (calculated on a four domain structure). WHOQOL-BREF domain scores demonstrated good discriminant validity, content validity, internal consistency and test–retest reliability.

Conclusion. These data suggest that the WHOQOL-BREF provides a valid and reliable alternative to the assessment of domain profiles using the WHOQOL-100. It is envisaged that the WHOQOL-BREF will be most useful in studies that require a brief assessment of quality of life, for example, in large epidemiological studies and clinical trials where quality of life is of interest. In addition, the WHOQOL-BREF may be of use to health professionals in the assessment and evaluation of treatment efficacy.

Background. It has been suggested that patients with unipolar depression show abnormal responses to negative feedback in the performance of cognitive tasks. Positron emission tomography (PET) has previously identified blood flow abnormalities in depressed patients during cognitive performance. We have also used PET to identify regions where there is differential neural response to performance feedback in normal volunteers. In this study we aimed to test the hypothesis that blood flow in these regions, the medial caudate and ventromedial prefrontal cortex, would be abnormal in depressed patients.

Methods. Six patients with unipolar depression and six matched controls were scanned using PET while performing cognitive tasks in the presence and absence of feedback.

Results. Compared with controls, depressed patients failed to show significant activation in the medial caudate and ventromedial orbitofrontal cortex. Blood flow was lower and a differential response, observed in normals, under different task and feedback conditions was not seen in the patients.

Discussion. The findings suggest that the behavioural response to feedback in depressed patients is associated with an abnormal neural response within the medial caudate and ventromedial orbitofrontal cortex, regions implicated in reward mechanisms. We argue that the observed abnormalities may depend on a combination of psychological factors, with both cognitive and emotive components.

Background. Depressed patients show deficits on neuropsychological tests. However, the basis of these impairments and their relationship with mood disturbance remains unclear.

Methods. This paper reviews the literature regarding the relationship between mood disturbance and neuropsychological impairment in depression and the evidence for serotonergic and hypothalamic–pituitary–adrenal (HPA) axis involvement in these two domains.

Results. Mood disturbance and neuropsychological impairment both occur in depression, but have no clear relationship in time or degree. Impairment of post-synaptic 5-HT1A receptor function may result in the symptom of low mood in depression. Depressed patients demonstrate abnormalities in the functional control of the HPA axis with a resultant hypercortisolaemia, which may impair neuropsychological function. These processes may be related given the extensive interactions between the serotonergic system and the HPA axis.

Conclusions. We argue that there is a neurobiological cause of impaired neuropsychological function in depression. The complex relationship between neuropsychological function and mood may be a result of interactions between the serotonergic system and the HPA axis, particularly in the hippocampus with involvement of serotonergic 5-HT1A and glucocorticoid receptors. A primary dysfunction in these receptors will produce a lowering of mood and neuropsychological impairment respectively. Either dysfunction will result in a secondary impairment of the alternate system. Thus, the affective and psychological changes of depressive illness are likely to have complex relationships in time and severity to one another and the illness as a whole may result from a range of primary aetio-pathologies.

Background. The social rank theory of psychopathology suggests that with the evolution of social hierarchies various psychobiological mechanisms became attuned to the success or failure in conflict situations. Specifically, subordinates and those who have lost status are at greater risk of pathology than winners and those of higher status. In this theory concepts of defeat and entrapment are seen to be of special relevance to the study of depression. We outline the role of defeat and entrapment within the social rank theory of depression.

Methods. New self-report measures of entrapment and defeat were developed and used to test predictions of the social rank theory of depression. Both a sample of students and depressed patients were assessed with these new scales and other social rank measures (e.g. social comparison and submissive behaviour).

Results. The entrapment and defeat measures were found to have good psychometric properties and significantly correlated with depression. They were also strongly associated with other rank variables. Defeat maintained a strong association with depression even after controlling for hopelessness (r=0·62), whereas the relationship between hopelessness and depression was substantially reduced when controlling for defeat. Entrapment and defeat added substantially to the explained variance of depression after controlling for the other social rank variables.

Conclusions. Defeat and entrapment appear to be promising variables for the study of depression. These variables may also help to develop linkages between human and animal models of psychopathology.

Background. We sought to determine whether there was empirical support for the diagnostic thresholds of DSM-IV bulimia nervosa (BN) and whether an empirically derived typology resembled the diagnostic categories of DSM-IV.

Methods. Detailed information about bulimic behaviours were assessed via personal interview in a population-based sample of 1897 Caucasian female twins. We assessed the lifetime prevalence of the component bulimic behaviours and DSM-IV and DSM-III-R BN. Latent class analysis of nine separate bulimic symptoms was used to develop an empirical typology of bulimic behaviour.

Results. Although the lifetime prevalences of bingeing (23·6%) and vomiting (4·8%) were relatively common, DSM-IV BN was distinctly uncommon (0·5%). The criterion that specified the frequency and duration of bingeing and vomiting was an important limiting condition. Analysis of alternative thresholds found little support for the DSM-IV thresholds requiring an average of twice per week for 3 months. Latent class analysis yielded an interpretable four class solution that had little overlap with the DSM-IV typology.

Conclusions. As in other studies of unselected samples of women, the lifetime presence of bulimic behaviours are relatively high. Our results suggest that the DSM-IV approach to categorizing bulimic behaviour inadequately captures the spectrum of lifetime bulimic behaviours in the general population.

Background. One hundred and thirty-five women with bulimia nervosa participated in a randomized clinical trial designed to determine whether the addition of exposure with response prevention to a core of cognitive-behavioural therapy (CBT) leads to greater clinical improvement and lower risk of relapse. We present results from the end of treatment and 6- and 12-month follow-up.

Methods. Participants received eight sessions of CBT and were then randomized to either exposure to pre-binge cues (B-ERP), exposure to pre-purge cues (P-ERP), or a relaxation training control condition (RELAX).

Results. CBT produced significant clinical change. At the end of the behavioural treatments, there were no significant differences across the three groups on abstinence (66% in B-ERP, 45% in P-ERP and 47% in RELAX), or frequency of bingeing and purging. B-ERP, but not P-ERP, significantly reduced anxiety on the cue reactivity assessment, food restriction, body dissatisfaction and depression. These differences were not maintained at 6-month follow-up. At 12-months, B-ERP was independently associated with lower food restriction and better global functioning.

Conclusions. CBT is a highly effective treatment for bulimia nervosa. B-ERP was modestly superior to P-ERP at post-treatment; however, the advantage did not remain throughout the follow-up interval. ERP for bulimia nervosa is an expensive and logistically complicated treatment that does not appear to offer any significant additive benefits that are proportional to the amount of effort required to implement the treatment.

Background. Twin studies have long been used to disentangle the role of genetic and environmental factors in the aetiology of psychiatric disorders. However, the validity of the twin method depends on the equal environment assumption – that monozygotic (MZ) and dizygotic (DZ) twins are equally correlated in their exposure to environmental factors of aetiological importance for the disorder under study.

Methods. Both members of 822 female–female twin pairs from a population-based registry previously assessed for a range of psychiatric and substance use disorders were asked 12 questions assessing the similarity of their environmental experiences in childhood and adolescence. We examined whether the similarity of environmental experiences predicted concordance for psychiatric and substance abuse disorders by both a ‘pair-wise’ and ‘individual’ method utilizing logistic regression. We also examined smoking initiation, where prior evidence suggested a role for adolescent social environment.

Results. Three factors were derived from these items: ‘Childhood treatment’, ‘Co-socialization’ and ‘Similitude’. Members of twin pairs agreed substantially in their recollections of these experiences. Compared with DZ twins, MZ twins reported comparable resemblance in their childhood treatment, but socialized together more frequently and reported that parents, teachers and friends more commonly emphasized their similarities. None of these three factors significantly predicted twin resemblance for major depression, generalized anxiety disorder, panic disorder, phobias, nicotine dependence or alcohol dependence. However, co-socialization significantly predicted twin resemblance for smoking initiation and perhaps for bulimia.

Conclusion. Differential environmental experiences of MZ and DZ twins in childhood and adolescence are unlikely to represent a substantial bias in twin studies of most major psychiatric and substance dependence disorders but may influence twin similarity for the initiation of substance use.

Background. Previous research has shown an increased risk of mortality after spousal bereavement, with the highest risk in the first weeks or months closest to the loss. One difficult issue in these designs is appropriate covariates and control groups.

Method. This study is based on 1993 pairs of twins discordant for marital status and on 35860 married individuals from the Swedish Twin Registry born between 1886 and 1958 and followed for marital and vital status between 1981 and 1993.

Results. Spousal bereavement was a risk factor for mortality for both men and women using the still married co-twin as a control to the widowed proband, and controlling for earlier health status and health-related risk factors. The mortality risk was higher for young-old (under 70 years) individuals, and for recently widowed than for longer-term widowed. Young-old women had a pattern with increased mortality risk during the first years after bereavement, but also a markedly decreased risk if they survived 4 years after bereavement, as compared to married women.

Conclusions. The results support a causal effect of bereavement on mortality. The decrease in risk for long-term young-old women is congruent with reports by widows of psychological growth after bereavement, involving increased sense of mastery and competence after learning to live in new sets of circumstances following the loss of their husband.

Background. Substantial variability in age at onset of illness and course of illness exists between patients with schizophrenia. Recent studies suggest that age at illness onset may be useful in defining biologically and clinically distinct subgroups of patients.

Methods. Two hundred and ten males with schizophrenia were classified as early-onset or adult-onset according to their age at first hospitalization. Birth history, clinical functioning and treatment response was assessed in a subgroup of patients. Brain anatomy was assessed from CT scans in all patients and in 32 non-psychiatric control subjects.

Results. Patients with an early-onset were likely to have a history of obstetric complications, a poor response to neuroleptic treatment, and showed no relationship between ventricle size and duration of illness. Adult-onset patients were less likely to have obstetric complications, more likely to respond to treatment in the first years of illness, and showed an association between brain structure and duration of illness.

Conclusions. The distinction between early- and adult-onset patients may have important aetiological and treatment implications.

Background. Morphometry, the measurement of forms, is an ancient practice. In particular, schizophrenic somatology was popular early in this century, but has been essentially absent from the literature for over 30 years. More recently, evidence has grown to support the notion that aberrant neurodevelopment may play a role in the pathophysiology of schizophrenia. Is the body, like the brain, affected by abnormal development in these patients?

Methods. To evaluate global deficit in development and its relationship to pre-morbid function, height was compared in a large group (N=226) of male schizophrenics and a group of healthy male controls (N=142) equivalent in parental socio-economic status. Patients in the lower quartile of height were compared to those in the upper quartile of height.

Results. The patient group had a mean height of 177·1 cm, which was significantly shorter than the mean height of the control group of 179·4 (P<0·003). Those in the lower quartile had significantly poorer pre-morbid function as measured by: (1) psychosocial adjustment using the pre-morbid adjustment scales for childhood and adolescence/young adulthood, and (2) cognitive function using measures of school performance such as grades and need for special education. In addition, these measures of pre-morbid function correlated significantly with height when analysed using the entire sample.

Conclusions. These findings provide further support to the idea that abnormal development may play a key role in the pathophysiology of schizophrenia. Furthermore, this is manifested as a global deficit in growth and function resulting in smaller stature, poorer social skills, and deficits in cognitive abilities.

Background. Capacity limitation theories have proved to be surprisingly resilient in characterizing some of the cognitive deficits in schizophrenia. However, this perspective has not generally been applied to short-term verbal memory tasks. We explored this issue by first attempting to ascertain if gross misallocations of processing resources might explain impairments in short-term memory in schizophrenia on a classic digit span task and in a second study by attempting to determine what effects delay and memory set size had on a divided attention short-term verbal memory paradigm.

Methods. In the first study 16 patients with schizophrenia and 21 normal controls received 40 trials of a three digit task and 20 trials of a six digit span task. As the absolute number of digits presented and duration of presentation in two conditions were identical, subjects thus had equivalent ‘opportunities’ to make errors if distraction, in the sense of misallocation of cognitive resources, were at the root of poor performance. In the second study 15 patients with schizophrenia and 15 normal controls were tested in conditions in which two, four or six words were presented and in which rehearsal was prevented by an interference task (colour naming) for delays of 5, 10 or 15 s.

Results. Patients had disproportionate difficulty on the six digit rather than the three digit condition, suggesting that deficits in the verbal working memory short-term store may not be the result of attentional factors. In the second study, patients' performance was differentially worsened by the interference task, by memory set size (i.e. a capacity limitation) and by delay, a measure of decay rate.

Conclusions. In concert, these studies demonstrate that schizophrenia patients have difficulties on verbal short-term memory span tasks not because of misallocation of resources, but rather because of limitations in ‘representational capacity’ and maintenance of information over delays.

Background. Frith & Done (1988) have proposed that the experience of alien control symptoms in schizophrenia is related to a failure by such individuals to monitor effectively their own willed intentions, actions and thoughts.

Method. To examine this hypothesis, a heterogeneous group of 35 patients, all carrying a DSM-III-R diagnosis of schizophrenia (or schizophreniform psychosis) and 24 non-patient controls, completed a battery of neuropsychological and cognitive tests, which inter alia, included four putative measures of self-monitoring. Patients took part in a detailed clinical interview to assess current levels of symptomatology.

Results. Patients generally performed at a lower level on most components of the test battery, including the four self-monitoring tests. Moreover, patients currently experiencing symptoms of alien control tended to experience greater difficulty with each of the self-monitoring tests; an effect that was relatively independent of neuropsychological or general cognitive function.

Conclusions. The relationship between poor self-monitoring and the presence of alien control symptoms provides support for Frith & Done's account of the origins of these symptoms in schizophrenia.

Background. Previous studies of oculomotor dysfunction in schizophrenia have tended to concentrate on abnormalities of smooth pursuit eye tracking in chronic medicated patients. We report the results of a study of smooth pursuit, reflexive and antisaccade performance in drug naive and antipsychotic treated first-episode schizophrenic patients.

Methods. Smooth pursuit and saccadic eye movements were recorded in 36 first-episode schizophrenic patients and 36 controls matched for age and estimated IQ. The schizophrenic patients were divided into drug-naive (N=17) and antipsychotic treated groups (N=19).

Results. Smooth pursuit velocity gain was significantly lower than controls only in the drug-naive patients. The treated patients did not differ significantly from either the controls or the untreated group. In an antisaccade paradigm both treated and drug-naive schizophrenic patients demonstrated an increased number of errors, but only drug-naive patients also demonstrated an increased latency in initiating correct antisaccades.

Conclusions. These impairments are unlikely to be due to a generalized deficit in oculomotor function in the schizophrenic groups, as there were no differences between the groups in saccadic metrics on a reflexive saccade task. The results show that both smooth pursuit and saccadic abnormalities are present at the onset of schizophrenia and are integral to the disorder.

Background. Few data are available regarding the impact of improved depression treatment on daily functioning and disability.

Methods. In two studies of more intensive depression treatment in primary care, patients initiating antidepressant treatment were randomly assigned to either usual care or to a collaborative management programme including patient education, on-site mental health treatment, adjustment of antidepressant medication, behavioural activation and monitoring of medication adherence. Assessments at baseline as well as 4 and 7 months included several measures of impairment, daily functioning and disability[ratio ]self-rated overall health, number of bodily pains, number of somatization symptoms, changes in work due to health, reduction in leisure activities due to health, number of disability days and number of restricted activity days.

Results. Average data from the 4- and 7-month assessments in both studies, intervention patients reported fewer somatic symptoms (OR 0·68, 95% CI 0·46, 0·99) and more favourable overall health (OR 0·50, 95% CI 0·28, 0·91). While intervention patients fared better on other measures of functional impairment and disability, none of these differences reached statistical significance.

Conclusions. More effective acute-phase depression treatment reduced somatic distress and improved self-rated overall health. The absence of a significant intervention effect on other disability measures may reflect the brief treatment and follow-up period and the influence of other individual and environmental factors on disability.

Background. There is little research that examines demographic, clinical and treatment factors associated with changes in physical symptoms, psychiatric symptoms and functional outcome in patients with somatized depression or anxiety in primary care.

Method. Factors associated with the outcome of psychologized or somatized depression or anxiety were derived from the literature. These factors were tested individually for their effects on changes in physical symptoms, psychiatric symptoms and functional outcome between baseline consultation with the general practitioner and 1 or 3 months later in 215 patients with somatized depression or anxiety. Individual factors associated with a particular outcome, demographic, DSM-IV diagnosis and treatment variables were entered into a multiple regression analysis.

Results. Factors associated with a better outcome on all three types of outcome measure were the absence of generalized anxiety disorder and/or simple or social phobias, absence of physical pathology, and the prescription of fewer drugs, especially hypnotics or benzodiazepines. In addition, a better psychiatric symptom outcome was associated with the patients' perceived satisfaction with the general practitioner's understanding or explanation of the patient's problems. A better functional outcome was associated with having a job, less distress over physical symptoms, not receiving invalidity benefit and no referral to hospital.

Conclusion. There are clinical and demographic factors associated with all types of short-term outcome in patients with somatized depression or anxiety but there are additional factors that are associated only with either psychiatric or functional outcome.