We are pleased to announce that from this month Psychological Medicine will be published monthly. Psychological Medicine has long had a tradition of issues which are substantial in thickness, and produce large annual volumes. With progressive expansion of the total number of pages published annually over the last ten years, we have moved from the previous quarterly issues to every two months and then to eight issues per year. Increasing to monthly issues will thin each issue a little but it coincides with a further increase in the total annual number of pages and of papers published. We will now be able to serve our authors better by publishing their papers more quickly. Since last year, all papers have also been published online rapidly, as soon as they have been typeset and proofread, well in advance of being assigned to a printed issue, further enhancing rapid dissemination to readers.

We are also making some changes in the regional distribution of editorial responsibilities. In future, papers from Europe and Australasia will continue to be handled by the UK Editorial Office but, in addition to papers from the Americas, those from Asia, Africa and the Middle East should be sent to the US Editorial Office.

This issue particularly features papers on treatment, including randomized controlled trials, studies derived from them, and follow-up studies.

Background. The nature of delusions remains unclear despite their interest to researchers and importance in psychopathology. Here we present a review of the contributions from various disciplines, principally cognitive neuroscience, towards a new understanding.

Method. Narrative review of published research.

Results. The main areas of activity revolve around reasoning biases, attributional and attentional biases, theory of mind, and the role of emotion, with each area beginning to be explored using functional neuroimaging techniques. Of heuristic interest are neurological models, which include confabulation and delusional misidentification and the one- versus two-stage (perceptual versus reasoning plus perceptual) accounts of the latter.

Conclusions. These different approaches are shown to each highlight mechanisms which are suggested to cause, contribute to, or modulate the genesis and form of delusions. Such contributions coupled with traditional phenomenological methods should provide the foundations for a cognitive neuropsychiatry of delusions.

Background. Despite the availability of efficacious medications and psychotherapies, care of bipolar disorder in everyday practice is often deficient. This trial evaluated the effectiveness of a multi-component care management program in a population-based sample of people with bipolar disorder.

Method. Four hundred and forty-one patients treated for bipolar disorder during the prior year were randomly assigned to continued usual care or usual care plus a systematic care management program including: initial assessment and care planning, monthly telephone monitoring including brief symptom assessment and medication monitoring, feedback to and coordination with the mental health treatment team, and a structured group psychoeducational program – all provided by a nurse care manager. Blinded quarterly assessments generated week-by-week ratings of severity of depression and mania symptoms using the Longitudinal Interval Follow-Up Evaluation.

Results. Participants assigned to the intervention group had significantly lower mean mania ratings averaged across the 12-month follow-up period (Z=2·44, p=0·015) and approximately one-third less time in hypomanic or manic episode (2·59 weeks v. 1·69 weeks). Mean depression ratings across the entire follow-up period did not differ significantly between the two groups, but the intervention group showed a greater decline in depression ratings over time (Z statistic for group-by-time interaction=1·98, p=0·048).

Conclusions. A systematic care program for bipolar disorder significantly reduces risk of mania over 12 months. Preliminary results suggest a growing effect on depression over time, but longer follow-up will be needed.

Background. Many patients with major depression are non-adherent to antidepressant medication and do not receive care according to current guidelines. There is increasing evidence that treatment of depression in primary care can be improved. Comparison between effective interventions may help to establish the active ingredients of such interventions.

Method. In a randomized trial two interventions to improve treatment of major depression in primary care were compared (1) a depression care programme, targeting general practitioners (GPs), patients, and systematic follow-up, and (2) a systematic follow-up programme. Thirty GPs were randomized and 211 primary-care patients with current major depression were included. All patients were prescribed a selective serotonin reuptake inhibitor. Outcome measures included adherence to antidepressant medication, and depression outcome.

Results. No significant differences in adherence rates and treatment outcome measures were demonstrated between interventions at week 10 or week 26. Adherence rates were high and treatment outcome was favourable.

Conclusions. The depression care programme was not superior to the systematic follow-up programme. Systematic follow-up in depression treatment in primary care seems to be an intervention per se, having the potential to improve adherence and treatment outcome.

Background. In order to improve care for people with depressive disorders and to reduce the increasing burden of depression, the American Regional Office of the World Health Organization has launched a major region-wide initiative. A central part of this effort was directed to the primary care system where the diagnosis and treatment of depression are deficient in many countries. This study evaluated the materials developed by the World Psychiatric Association in a training program on depression among primary care physicians by measuring changes in their knowledge, attitudes, and practice (KAP).

Method. One hundred and seven physicians and 6174 patients from five Latin American countries participated in the trial. KAP were assessed 1 month before and 1 month following the training program. In addition, the presence of depressive symptoms was measured in patients who visited the clinic during a typical week at both times using the Zung Depression Scale and a DSM-IV/ICD-10 major depression checklist.

Results. The program slightly improved knowledge about depression and modified some attitudes, but had limited impact on actual practice. There was no evidence that the diagnosis of depression was made more frequently, nor was there an improvement in psychopharmacological management. The post-training agreement between physician diagnosis and that based on patient self-report remained low. The physicians, however, seemed more confident in treating depressed patients after training, and referred fewer patients to psychiatrists.

Conclusions. Traditional means of training primary care physicians in depression have little impact on clinical practice regardless of the quality of the teaching materials.

Background. A limited number of psychotherapy sessions in combination with medication is preferable to pharmacotherapy only in the treatment of ambulatory patients with major depression. Whether there is a relation between the number of sessions and the efficacy of the treatment is uncertain.

Method. Randomized clinical trial comparing two treatment conditions in outpatients with major depression. All patients studied had a baseline score of at least 14 points on the 17-item Hamilton Depression Rating Scale. The two conditions consist of 8-session or 16-session Short Psychodynamic Supportive Psychotherapy, both in combination with pharmacotherapy. Efficacy was assessed using the 17-item HDRS, the CGI of Severity and of Improvement, the depression subscale of the SCL-90 and the Quality of Life Depression Scale.

Results. The rate of change would seem to indicate that eight sessions are preferable for both moderately and severely depressed patients, although the results converged again at the end. Furthermore, in terms of satisfaction with the number of sessions and drop-out percentages during treatment, no differences were found between the conditions.

Conclusion. In the light of the outcome analysis (faster remission after fewer sessions), a short version of the psychotherapy treatment in a combined course of treatment seems to be justified.

Background. Although there is good evidence that cognitive therapy (CBT) lessens relapse and recurrence in unipolar depression, the duration of this effect is not known.

Method. One hundred and fifty-eight subjects, from a randomized controlled trial of CBT plus medication and clinical management versus medication and clinical management alone, were followed 6 years after randomization (4½ years after completion of CBT) and the longitudinal course assessed.

Results. Effects in prevention of relapse and recurrence were found to persist, with weakening, and were not fully lost until 3½ years after the end of CBT. Residual symptoms were also lessened.

Conclusions. The effect of CBT in reduction of relapse and recurrence persists for several years. The potential value of subsequent additional CBT some time after cessation should be explored.

Introduction. Cognitive therapy (CT) for bipolar disorder emphasizes the monitoring and regulation of mood, thoughts and behaviour. The Sense of Hyper-Positive Self Scale (SHPSS) measures the extent to which bipolar patients value themselves and perceive themselves to possess personal attributes (e.g. dynamism, persuasiveness and productiveness) associated with a state of being ‘mildly high’, which does not reach the severity of clinical hypomania. It is hypothesized that patients who score highly on the SHPSS do not respond well to cognitive therapy.

Method. One hundred and three bipolar-I patients were randomized into CT and control groups. The SHPSS was administered at baseline and at a 6-month follow-up.

Result. The SHPSS had good test–retest reliability after 6 months. At baseline, the Goal-Attainment Dysfunctional Attitudes contributed significantly to the SHPSS scores after the mood measures were controlled for in a regression analysis. There was a significant interaction between baseline SHPSS scores and group allocation in predicting relapse during therapy. Patients who scored highly on the SHPSS had a significantly increased chance of relapse after controlling for mood scores, levels of social functioning at recruitment, and the previous number of bipolar episodes.

Conclusion. Not all patients benefited from CT. For patients with high SHPSS scores, CT was less efficacious. The results also indicate that future studies could evaluate targeting these attributes and dysfunctional beliefs with intensive cognitive behavioural techniques.

Background. Borderline personality disorder (BPD) is a serious mental illness. Due to scepticism about the effectiveness of its treatment, the care of these patients is neglected. In this study we evaluated the effect of treatment 5 years after its ending, of patients with BPD.

Method. Thirty subjects were treated twice weekly for 1 year by psychotherapy based on the ‘Conversational Model’ of Hobson. Outcome measures included time in hospital, number of episodes of violence and self-harm, number of medical appointments, drug use and work history. A ‘morbidity budget’ made up of these items was collated for the year before treatment, the year following treatment, and for the year preceding the 5-year follow-up. Additional measures included DSM-III criteria and a self-report of symptoms. These outcomes were compared to a hypothetical natural history of BPD constructed from the DSM scores of 150 borderline patients aged between 18 and 52 years.

Results. Except for one measure, the improvements evident 1 year following treatment were maintained 4 years later. This improvement was not predicted by the hypothetical natural history.

Conclusion. A particular form of treatment of BPD has relatively long-lasting, beneficial effects.

Background. We prospectively studied outcomes of sex reassignment, potential differences between subgroups of transsexuals, and predictors of treatment course and outcome.

Method. Altogether 325 consecutive adolescent and adult applicants for sex reassignment participated: 222 started hormone treatment, 103 did not; 188 completed and 34 dropped out of treatment. Only data of the 162 adults were used to evaluate treatment. Results between subgroups were compared to determine post-operative differences. Adults and adolescents were included to study predictors of treatment course and outcome. Results were statistically analysed with logistic regression and multiple linear regression analyses.

Results. After treatment the group was no longer gender dysphoric. The vast majority functioned quite well psychologically, socially and sexually. Two non-homosexual male-to-female transsexuals expressed regrets. Post-operatively, female-to-male and homosexual transsexuals functioned better in many respects than male-to-female and non-homosexual transsexuals. Eligibility for treatment was largely based upon gender dysphoria, psychological stability, and physical appearance. Male-to-female transsexuals with more psychopathology and cross-gender symptoms in childhood, yet less gender dysphoria at application, were more likely to drop out prematurely. Non-homosexual applicants with much psychopathology and body dissatisfaction reported the worst post-operative outcomes.

Conclusions. The results substantiate previous conclusions that sex reassignment is effective. Still, clinicians need to be alert for non-homosexual male-to-females with unfavourable psychological functioning and physical appearance and inconsistent gender dysphoria reports, as these are risk factors for dropping out and poor post-operative results. If they are considered eligible, they may require additional therapeutic guidance during or even after treatment.

Background. Serotonin is a good candidate for major depression. We attempted to replicate the study by Caspi and colleagues [Science (2003) 301, 386–389] which reported a significant interaction between serotonin transporter (5-HTTLPR) genotype and stressful life events when predicting major depression.

Method. We typed the serotonin promoter 5-HTTLPR gene in 1206 male and female twins aged 19–78 years (mean=39, S.D.=11). A DSM-IV diagnosis of major depression was available for 1199 twins. Most of these twins had participated in a 1988–1990 study which included a stressful life events inventory and self-report measure of depression based on the SCL-90 and DSSI/sAD. Complete 5-HTT genotype and life events data, self-report symptoms and major depression diagnoses were available for 1091 subjects. We regressed categorical and ordinal measures of depression onto stressful life events and genotype.

Results. There were significant main effects for stressful life events but there was no evidence for any effect of 5-HTT genotype, nor a genotype×stressful life event interaction.

Conclusions. Regardless of whether our results were based on binary logistic or ordinal regression analyses we found no evidence to support a main effect of 5-HTTLPR, or an interaction between the 5-HTTLPR genotype and stressful life events on major depression. Only 20% of our subjects were aged below 30 years. It is possible that the effect reported by Caspi and colleagues is specific to young people, in which case our study has much less power in this age group.

Background. Research on risk factors for burnout has mainly focused on circumstances at work and on personal characteristics. The aim of this study was to investigate whether burnout clusters within families and, if so, whether this is due to genetic influences or to environmental factors shared by family members. Finally, we tried to identify specific risk factors for burnout.

Method. In 2707 twins, 736 of their siblings and 575 of their spouses from a population-based twin-family sample, burnout was measured using a self-report questionnaire. Correlations in burnout scores were obtained for monozygotic and dizygotic twin pairs and sibling pairs conditional on the pairs' sex. Correlations for twins and their spouses were derived conditional on the length of the relationship.

Results. In the final model, correlations of the monozygotic and dizygotic twin pairs and sibling pairs were significantly different from zero, but not significantly different from each other. The correlation was estimated at 0·22. The correlation between spouses was also significant. This was mainly due to the group with a relationship longer than 5 years in which the correlation was 0·24. Burnout scores were higher in subjects whose parents had a high level of education.

Conclusions. There is familial clustering for burnout due to environmental factors shared by family members, explaining 22% of the variance. Genetic factors do not seem to be of importance. The significant correlation between spouses supports the conclusion that common environment plays a role in burnout. A high parental education is one of the familial risk factors.

Background. It has been hypothesized that the schizophrenic symptom of formal thought disorder is linked to both executive and semantic dysfunction.

Method. Intellectually preserved schizophrenic patients with (n=15) and without (n=16) formal thought disorder, plus matched normal controls (n=17) were administered four executive and four semantic tests. Tests of verbal fluency and comprehension of grammar were also given.

Results. The patients with formal thought disorder were significantly impaired on all four executive tests compared to the patients without the symptom. They were only impaired compared to non-thought-disordered patients on 1 of 4 semantic tests, which probed semantic associations between concepts. Naming performance did not distinguish the two groups, nor did a previously used measure of semantic fluency controlling for phonological fluency.

Conclusions. The results provide support for a dysexecutive hypothesis of formal thought disorder in schizophrenia, and, in line with other studies, suggest that there may be a restricted ‘higher-order’ semantic deficit which spares naming.

Background. In a broad cognitive study of schizophrenia we investigated the relationships of verbal memory impairments with cognitive underpinnings on the one hand, and clinical symptomatology on the other. The results have been reported in previous papers. In this paper we show how all these data could be integrated into a consistent pattern of associations.

Method. Fifty schizophrenic patients underwent a cognitive battery including a verbal memory task with free recall and recognition, a source memory task, and tests of processing speed and selective attention. Ratings for positive, negative and depressive symptoms were available for 40 of the patients.

Results. A factorial analysis revealed a distinction between measures of memory efficiency and measures of memory errors. The system of memory efficiency was associated with processing speed and selective attention at the cognitive level, and with depression at the symptom level. The system of memory errors was assumed to be underlain by source-monitoring deficits. These memory errors were increased by positive symptoms and decreased by certain negative symptoms.

Conclusions. All the measures drawn from various memory tasks could be integrated into a model describing their associations with cognitive underpinnings and clinical symptomatology. This model provides a heuristic for the cognitive and pharmacological treatments of verbal memory impairments in schizophrenia, as well as for the understanding of positive symptoms.