Background. The concept of duration of untreated psychosis (DUP) has recently attracted much interest because of its possible relationship to treatment outcome and implications for preventive efforts with reference to psychotic disorders, especially schizophrenia. In this paper we review critically the literature concerning the concept and its importance.

Methods. Articles concerned with measuring DUP and those that have been suggested to provide indirect or direct evidence of the effect of DUP on treatment outcome are reviewed.

Results. Evidence thus far suggests that DUP may be related to ease of reducing psychotic symptoms once treatment begins for first episode patients, but there is no evidence of a relationship to likelihood of relapse. There has been little investigation of the relationship of DUP to other long-term outcomes such as negative symptoms and cognitive functioning neither have the possible confounds of DUP been widely investigated or controlled.

Conclusions. It is important that there should be more thorough investigations of DUP, its correlates, and the extent to which it does mediate any advantages of earlier intervention.

Background. The overall aim of the GENESiS project is to identify quantitative trait loci (QTLs) for anxiety/depression, and to examine the interaction between these loci and psychosocial adversity. Here we present life-events data with the aim of clarifying: (i) the aetiology of life events as inferred from sibling correlations; (ii) the relationship between life events and measures of anxiety and depression, as well as neuroticism; and (iii) the interaction between life events and neuroticism on anxiety/depression indices.

Methods. We assessed the occurrence of one network and three personal life-event categories and multiple indices of anxiety/depression including General Health Questionnaire, Anhedonic Depression, Anxious Arousal and Neuroticism in a large community-based sample of 2150 sib pairs, 410 trios and 81 quads. Liability threshold models and raw ordinal maximum likelihood were used to estimate within-individual and between-sibling correlations of life events. The relationship between life events and indices of emotional states and personality were assessed by multiple linear regression and canonical correlations.

Results. Life events showed sibling correlations of 0·37 for network events and between 0·10 and 0·19 for personal events. Adverse life events were related to anxiety and depression and, to a less extent, neuroticism. Trait-vulnerability (as indexed by co-sib's neuroticism, anxiety and depression) accounted for 11% and life events for 3% of the variance in emotional states. There were no interaction effects.

Conclusions. Life events show moderate familiality and are significantly related to symptoms of anxiety and depression in the community. Appropriate modelling of life events in linkage and association analyses should help to identify QTLs for depression and anxiety.

Background. Genetic effects upon behaviour are pervasive. To what extent are the many correlates of major depression (MD) due to individual-specific environmental experiences versus genetic factors correlated with risk for MD?

Methods. From a population-based twin registry, we identified 72 female monozygotic pairs discordant for a lifetime history of MD and compared the affected and unaffected members on a wide range of putative correlates of MD.

Results. The affected twin differed from her unaffected co-twin on many variables, eight of which were maximally discriminating: (i) maternal protectiveness; (ii) conflictual parent–child relationship; (iii) low optimism; (iv) current stressful life events; (v) financial difficulties and a history of (vi) phobia, (vii) nicotine dependence; and (viii) divorce. A cluster analysis suggested three ‘environmental pathways' to MD characterized by: (i) childhood vulnerability and anxiety; (ii) acting-out and demoralization; and (iii) interpersonal difficulties.

Conclusion. Important precursors and sequelae of MD originate in environmental experiences unique to the individual and are not mediated through genetic factors or family-of-origin effects. Such environmental factors cause pervasive differences in monozygotic twins discordant for MD, especially in the areas of interpersonal difficulties, psychopathology, social problems and self-concept. These findings should be interpreted in the context of possible retrospective recall bias and the difficulty of distinguishing risk factors from sequelae in co-twin–control studies.

Background. Several case reports and reviews have suggested an increased incidence of schizophrenia or bipolar disorder among persons with sex chromosome aneuploidies, but this observation may have been caused by biased sampling.

Methods. The 1122 individuals with sex chromosome aneuploidies registered in the Danish Cytogenetic Central Register were screened in the Danish Psychiatric Central Register for admissions with schizophrenia or bipolar affective disorder. Both registers are population based and have existed since 1968 and 1969 respectively. Relative risks were calculated for schizophrenia, bipolar affective disorder and either schizophrenia or bipolar disorder combined as one phenotype. Since hospitalization for a psychiatric disorder increases the probability that a cytogenetic examination is performed, the relative risks could be inflated, and they were therefore adjusted accordingly.

Results. Aneuploidies of the X or Y chromosomes were not associated with an increased risk of schizophrenia or bipolar disorder. The occurrence of the combined phenotype including both schizophrenia and bipolar disorder was significantly reduced among persons with Turner's syndrome and significantly increased among individuals with the 47, XYY karyotype.

Conclusions. This population-based study did not find evidence supporting the presence of risk alleles for schizophrenia or bipolar disorder on the X chromosome or the pseudoautosomal region on the Y chromosome. The findings of an increased risk for the combined phenotype to XYY males and the reduced risk for persons with Turner's syndrome are interesting but difficult to explain with present neurobiological knowledge and inconsistent with the other findings of the study.

Background. Subjective memory impairment (SMI) is common in older populations but its aetiology and clinical significance is uncertain. Depression has been reported to be strongly associated with SMI. Associations with objective cognitive impairment are less clear cut. Other factors suggested to be associated with SMI include poor physical health and the apolipoprotein E (APOE) ε4 allele. Studies of SMI have been predominantly confined to white Caucasian populations.

Method. A community study was carried out in a UK African-Caribbean population aged 55–75, sampled from primary care lists. Twenty-three per cent were classified with SMI. Depression was defined using the 10-item Geriatric Depression Scale. Other aetiological factors investigated were education, objective cognitive function, APOE genotype, disablement and vascular disease/risk. The principal analysis was restricted to 243 participants scoring > 20 on the Mini-Mental State Examination (85%). A second analysis included all 290 participants.

Results. Depression, self-reported physical impairment and APOE ε4 were associated with SMI. The association between SMI and physical impairment was not explained by depression, vascular disease/risk, or disability/handicap. The association between ε4 and SMI increased as MMSE scores decreased and was particularly strong in those with depression. The ε4 allele was present in 69% (95% CI 41–89%) of those with depression and SMI compared with 28% (20–36%) of those with neither.

Conclusions. Depression may not be a sufficient explanation for subjective memory complaints. Memory complaints in the presence of depression are associated with high prevalence of ε4 and therefore, presumably, a raised risk of subsequent dementia.

Background. There is considerable dispute about the validity of memory complaints. While some studies find that complaints are an early indicator of dementia or cognitive decline, there are also many studies showing that complaints are more closely associated with negative affect (depression, anxiety and neuroticism). The present paper used three-wave longitudinal data to test three hypotheses: (1) that memory complaints reflect an evaluation of present and past memory performance; (2) that memory complaints predict future memory performance; and (3) that memory complaints predict current and future negative affect.

Methods. A longitudinal study was carried out with a community sample of people aged 70 and over. Participants were assessed for memory complaints, memory performance and negative affect at three waves separated by 3·6 years and 4·0 years. There were 331 persons with data on all relevant variables. The data were analysed using structural equation modelling.

Results. Significant paths in the structural model were found from memory performance to future memory complaints, as well as from memory complaints to future memory performance, supporting hypotheses 1 and 2. Memory complaints were associated with current negative affect, but did not predict future negative affect.

Conclusions. Memory complaints do reflect perceptions of past memory performance and are also an early manifestation of memory impairment. However, current negative affect (anxiety and depression symptoms) shows the greatest association with memory complaints.

Background. The National Adult Reading Test (NART) is widely used in research and clinical practice as an estimate of pre-morbid or prior ability. However, most of the evidence on the NART's validity as a measure of prior intellectual ability is based on concurrent administration of the NART and an IQ measure.

Method. We followed up 179 individuals who had taken an IQ test (the Moray House Test) at age 11 and administered the NART and the Mini-Mental State Examination (MMSE) at age 77. A subset (N=97) were also re-administered the original IQ test.

Results. The correlation between NART performance at age 77 and IQ age 11 was high and statistically significant (r=0·73; P<0·001). This correlation was comparable to the correlation between NART and current IQ, and childhood IQ and current IQ, despite the shared influences on the latter variable pairings. The NART had a significant correlation with the MMSE but this correlation fell to near zero (r=0·02) after partialling out the influence of childhood IQ.

Discussion. The pattern of results provides strong support for the claim that the NART primarily indexes prior (rather than current) intellectual ability.

Background. The efficacy and effectiveness of cognitive therapy (CT) is well established for unipolar disorders, but little is known about its utility in bipolar disorders. This study aimed to explore the feasibility and efficacy of using CT as an adjunct to usual psychiatric treatment in this patient population.

Method. Subjects referred by general adult psychiatrists were assessed by and independent rater and then randomly allocated to immediate CT (N=21) or 6-month waiting-list control, which was then followed by CT (N=21). Observer and self-ratings of symptoms and functioning were undertaken immediately prior to CT, after a 6-month course of CT and a further 6-months later. Data on relapse and hospitalization rates in the 18 months before and after commencing CT were also collected.

Results. At 6-month follow-up, subjects allocated to CT showed statistically significantly greater improvements in symptoms and functioning as measured on the Beck Depression Inventory, the Internal State Scale, and the Global Assessment of Functioning than those in the waiting-list control group. In the 29 patients who eventually received CT, relapse rates in the 18 months after commencing CT showed a 60% reduction in comparison with the 18 months prior to commencing CT. Seventy per cent of subjects who commenced therapy viewed CT as highly acceptable.

Conclusion. Although the results of this study are encouraging, the use of CT in subjects with bipolar disorders is more complex than in unipolar disorders and requires a high level of therapist expertise. The therapy may prove to be particularly useful in the treatment of bipolar depression.

Background. Chronic fatigue syndrome (CFS) and depression share a number of common symptoms and the majority of CFS patients meet lifetime criteria for depression. While cognitive factors seem key to the maintenance of CFS and depression, little is known about how the cognitive characteristics differ in the two conditions.

Methods. Fifty-three CFS patients were compared with 20 depressed patients and 38 healthy controls on perceptions of their health, illness attributions, self-esteem, cognitive distortions of general and somatic events, symptoms of distress and coping. A 6 month follow-up was also conducted to determine the stability of these factors and to investigate whether CFS-related cognitions predict ongoing disability and fatigue in this disorder.

Results. Between-group analyses confirmed that the depressed group was distinguished by low self-esteem, the propensity to make cognitive distortions across all situations, and to attribute their illness to psychological factors. In contrast, the CFS patients were characterized by low ratings of their current health status, a strong illness identity, external attributions for their illness, and distortions in thinking that were specific to somatic experiences. They were also more likely than depressed patients to cope with their illness by limiting stress and activity levels. These CFS-related cognitions and behaviours were associated with disability and fatigue 6 months later.

Conclusions. CFS and depression can be distinguished by unique cognitive styles characteristic of each condition. The documented cognitive profile of the CFS patients provides support for the current cognitive behavioural models of the illness.

Objective. This study investigates the relationship of specific anxiety and affective disorders to obsessive–compulsive disorder (OCD) in a blind, controlled family study.

Method. Eighty case and 73 control probands, as well as 343 case and 300 control first-degree relatives of these probands, participated in the study. Subjects were examined by psychologists or psychiatrists using the Schedule for Affective Disorder and Schizophrenia-Lifetime Anxiety version (SADS-LA). Two experienced psychiatrists independently reviewed all clinical materials, and final diagnoses were made according to DSM-IV criteria, by consensus procedure.

Results. Except for bipolar disorder, all anxiety and affective disorders investigated were more frequent in case than control probands. Substance dependence disorders were not more frequent. Generalized anxiety disorder (GAD), panic disorder, agoraphobia, separation anxiety disorder (SAD) and recurrent major depression were more common in case than control relatives. These disorders occurred more frequently if the relative was diagnosed with OCD. Only GAD and agoraphobia were more frequent in case relatives independent of OCD.

Conclusion. GAD and agoraphobia share a common familial aetiology with OCD. The other anxiety and affective disorders, when comorbid with OCD, may emerge as a consequence of the OCD or as a more complex syndrome.

Background. Global characteristics and psychosocial risk factors related to delusions have been identified. The present study extends these findings to the level of everyday functioning, identifying characteristics of delusional moments (DMs) and contextual risk and protective factors for delusional exacerbations in daily life.

Methods. Data were collected using the Experience Sampling Method (ESM), a time-sampling technique. Forty-eight chronic patients diagnosed with schizophrenia rated the intensity of pathological symptoms and mood states and described their thoughts and the environmental context during consecutive moments in daily life. Delusions were defined on the basis of self-rated suspicion, preoccupation, feeling controlled, and coded thought pathology. Daily context included current activity, persons present and location. Characteristics of DMs and non-delusional moments (nDMs) were compared, and a multilevel logistic regression model was used to identify contexts that might trigger or prevent DMs.

Results. On average, patients experienced delusions less than one-third of the time. DMs were characterized by higher negative affect and lower positive affect. The presence of family or acquaintances decreased the risk of subsequently experiencing a DM, whereas withdrawal from activities increased this risk.

Conclusions. Data support the validity of ESM for investigating delusions in schizophrenia. Daily life contexts appear to alter the probability that delusions will occur. Knowledge about such contexts may therefore be useful in helping patients develop better coping strategies and in creating therapeutic interventions that can lessen emotional distress.

Background. Abnormalities of face affect naming and face recognition occur in schizophrenia but it is not clear whether the deficits reflect wider underlying impairments of perception, memory, language or executive function.

Method. Twenty-six patients with schizophrenia were compared with 23 healthy volunteers on neuropsychological tests and tests of face and affect processing. Face and non-face tests were compared at four levels of processing: visuo-spatial perception, recognition memory, language and naming, and executive function. We examined relationships with drug dose, duration of illness and pre-morbid and current IQ.

Results. Patients and controls did not differ in estimated pre-morbid IQ but current IQ was 12 points lower in patients. At each level of processing there were correlated deficits of face and non-face processing in the patients that were mostly independent of IQ decline. Impaired face and non-face visuo-spatial function and recognition performance were generally correlated with drug dose. Impairments in naming face emotions were correlated with other non-face naming tasks independently of drug dose. Patients performed less well than controls in classifying faces by emotion while ignoring identity and this was associated with poorer performance in Wisconsin Card Sorting.

Conclusions. The pattern of results suggests that deficits in face processing reflect three wider neuropsychological impairments: a drug-related impairment of visual imagery, and disease-related impairments of semantic retrieval and executive function.

Background. Subjective evaluations by schizophrenic patients and their relatives of clozapine treatment were assessed as part of an exploratory study.

Methods. A problem-centred interview was carried out with 80 patients at discharge from in-patient or day-hospital treatment. Views of 46 relatives on the treatment were also assessed.

Results. In addition to expected effects (improvement of or stabilisation of one's state of mental health, antipsychotic effects), patients surprisingly often highlighted the calming and relaxing effect of clozapine as well as improved sleep as particularly positive. While more than half of the respondents expected a worsening of their condition if they stopped taking medication, only every fifth patient feared a relapse. Among the negative effects, fatigue and sedation were cited by far the most often. The absence of extrapyramidal side effects was clearly noted as an advantage of clozapine. Only 10 % of those questioned were aware of the risks for the haemotopoetic system associated with the drug. Differences were found between patients' and relatives' assessments particularly with regard to the negative effects.

Conclusions. Patients and relatives frequently hold specific and distinct views on clozapine treatment. These views should be considered when patients and relatives are informed and when compliance is addressed.

Background. In other branches of epidemiology, stratum specific likelihood ratios (SSLRs) have been found to be preferable to fixed best threshold approaches to screening instruments. This paper presents SSLRs of GHQ-12 and GHQ-28 and compares the SSLR method with the traditional optimal threshold approach.

Methods. Random effects meta-analysis and meta-regression were used to obtain pooled estimates of SSLRs of the two questionnaires for the 15 centres participating in the WHO study of Psychological Problems in General Health Care. We illustrated the use of SSLRs by applying them to random samples of patients from centres with different backgrounds.

Results. For developed and urban centres, the estimates of SSLRs were homogeneous for 10 out of 12 strata of the GHQ-12 and GHQ-28. For other centres, the overall results, which were heterogeneous for six out of 12 strata, were deemed the currently available best estimates. When we applied these results to centres with different prevalences of mental disorders and backgrounds, the estimates matched the actually observed closely. These examples showed how the SSLR approach is more informative than the traditional threshold approach.

Conclusions. Those working in developed urban settings can use the corresponding SSLRs with reasonable confidence. Those working in non-urban or developing areas may wish to use the overall results, while acknowledging that they must remain less certain until further research can explicate heterogeneity. These SSLRs have been incorporated into nomograms and spreadsheet programmes so that future researchers can swiftly derive the post-test probability for a patient or a group of patients from a pre-test probability and GHQ score.

Background. The planning and development of secure forensic psychiatry services for mentally disordered offenders in England and Wales has proceeded independently within different regional areas. However, certain mental disorders, offenders, and offending behaviour are all more prevalent in geographical areas characterized by socio-economic deprivation and social disorganization. Failure to consider these factors has led to inadequate service provision in some areas and inequity in funding. A new model is required to predict admissions to these services as an aid to resource allocation.

Method. Actual admissions (N=3155) to high and medium secure psychiatric services for seven of 14 (pre-reorganization) Regional Health Authorities, 1988–94. Expected admissions were calculated for each district using 1991 census data adjusted for under-enumeration. Standardized psychiatric admission ratios were calculated and a range of social, health status, and service provision data were used as explanatory variables in a regression analysis to determine variation between districts.

Results. Actual psychiatric admissions varied from 160% above to 62% below expected for age, sex, and marital status, according to patients' catchment area of origin, measured according to deciles of the distribution of underprivileged area scores at ward level. The most powerful explanatory variables included a composite measure of social deprivation, ethnicity and availability of low secure beds at regional level.

Conclusion. Admission rates to secure forensic psychiatry services demonstrate a linear correlation with measures of socio-economic deprivation in patients catchment area of origin. A model was developed to predict admissions from District Health Authorities and is recommended for future use in resource allocation. Identification of factors that explain higher admission rates of serious offenders with mental disorder from deprived areas is a priority for future research.

Background. The present study examined biases in visual attention for emotional material in children and adolescents with post-traumatic stress disorder (PTSD) and healthy controls.

Methods. The participants carried out an attentional deployment task in which probe detection latency data were used to determine the distribution of visual attention for threat-related and depression-related material.

Results. The results showed that children and adolescents with PTSD, relative to controls, selectively allocated processing resources towards socially threatening stimuli and away from depression-related stimuli. This attentional avoidance of depression-related information in the PTSD participants declined with age.

Conclusions. The results of the study are interpreted as a consolidation and extension of previous research on attentional bias and emotional disorder in younger participants.

Background. Studies in the northern and southern hemispheres consistently identify seasonal patterns in suicidal deaths. In many such studies, bimodal yearly peaks have been described for females as against unimodal ones for males. The current study examines the monthly variation in suicidal deaths in Singapore to determine if any seasonal patterns exist in an equatorial region.

Methods. Monthly suicidal death data over the decade 1989–98 were examined for the whole sample and for gender- and age-specific subgroups. Both von Mises' distribution and harmonic analysis techniques were used to interpret the data.

Results. Among the 2013 male and 1382 female suicides, there was minimal variation in patterning of suicidal deaths. We found a weak suggestion of a later peak for the females in mid-May as opposed to mid-February for the males, and the peaks for those less than 25 years of age were 5–6 months later than for the older age groups. The magnitude of all peaks was, however, very small suggesting chance variation. The harmonic analyses confirmed that patterning was ‘randomly' rather than ‘seasonally' determined.

Conclusion. In an equatorial region, there was no evidence of any ‘seasonal' patterning of suicidal deaths.

Background. Little is known about the prevalence of PTSD in primary-care settings and regarding the ability of primary-care physicians to detect PTSD. The current study examines prevalence of PTSD in a national sample of primary-care attenders and primary-care physicians' detection of PTSD and general psychological distress in PTSD patients.

Methods. Data are from a national study of 2975 primary-care attenders in Israel. Demographic data, responses to the GHQ-28, PTSD Inventory and physicians' diagnoses were examined.

Results. Twenty-three per cent of all patients who attended clinics (N=684) reported traumatic events, 39% of whom (males 37%, females 40%) met criteria for PTSD on the PTSD Inventory. Eighty per cent of the males and 92% of the females with PTSD were distressed according to the GHQ. According to physicians, 37% of persons who reported trauma (40% of the women, 32% of the men) suffered from psychological distress. Only 2% of patients meeting PTSD criteria on the self-report measure were given a diagnoses of PTSD by physicians.

Conclusions. Many primary-care patients suffer from PTSD, which is usually accompanied by major psychological distress. Attention by primary-care physicians to a history of trauma could improve physicians' detection of this disabling disorder.