Since the 1990s, facilities for individuals at putative risk for psychosis have mushroomed and within a very short time have become part of the standard psychiatric infrastructure in many countries. The idea of preventing a severe mental disorder before its exacerbation is laudable, and early data indeed strongly suggested that the sooner the intervention, the better the outcome. In this paper, the authors provide four reasons why they think that early detection or prodromal facilities should be renamed and their treatment targets reconsidered. First, the association between the duration of untreated psychosis and outcome is empirically established but has become increasingly weak over the years. Moreover, its applicability to those who are considered at risk remains elusive. Second, instruments designed to identify future psychosis are prone to many biases that are not yet sufficiently controlled. None of these instruments allows an even remotely precise prognosis. Third, the rate of transition to psychosis in at-risk patients is likely lower than initially thought, and evidence for the success of early intervention in preventing future psychosis is promising but still equivocal. Perhaps most importantly, the treatment is not hope-oriented. Patients are more or less told that schizophrenia is looming over them, which may stigmatize individuals who will never, in fact, develop psychosis. In addition self-stigma has been associated with suicidality and depression. The authors recommend that treatment of help-seeking individuals with mental problems but no established diagnosis should be need-based, and the risk of psychosis should be de-emphasized as it is only one of many possible outcomes, including full remission. Prodromal clinics should not be abolished but should be renamed and restructured. Such clinics exist, but the transformation process needs to be facilitated.

Background. Several studies have suggested that visual backward masking (VBM) impairment is present in patients with bipolar disorder, but the clinical features, such as current symptoms, treatment status and past burden of illness that may contribute to the impairment have not been well described. This study examined well-characterized euthymic patients on two VBM tasks to ascertain the extent of VBM impairment in this group and the clinical correlates of this impairment.

Method. Twenty-eight euthymic patients with a DSM-IV diagnosis of bipolar disorder were matched by age, sex and IQ with 28 non-psychiatric control subjects. Both groups completed two VBM tasks; one required subjects to locate the target stimulus, one required identification of the target stimulus. Reaction times and error rates across a range of target-mask inter-stimulus intervals were assessed.

Results. Patients were significantly slower and had more errors on both VBM tasks. There was a significant relation between reaction times on the identification task and past burden of illness, particularly past number of depressions. There was no discernible impact of treatment status on reaction time or performance, including no difference in lithium-treated versus not treated subjects.

Conclusions. These results are consistent with previous reports of neuropsychological deficits in euthymic bipolar disorder patients. The potential benefit to employing tasks such as VBM is that it may provide a method for relating clinical variables such as illness burden with known neural pathways in order to elucidate better the pathophysiology leading to impaired cognitive performance in patients with bipolar disorder.

Background. There is increasing evidence that subthreshold forms of psychopathology are both common and clinically relevant. To enable classification of these subthreshold forms of psychopathology, it may be useful to distinguish not only a threshold for illness but also for health. Our aim was to investigate this with regard to panic.

Method. Data were derived from the Netherlands Mental Health Survey and Incidence Study (NEMESIS), which is based on a large representative sample of the adult general population (18–65 years) of The Netherlands (n=7076). The Composite International Diagnostic Interview was used as a diagnostic instrument. By defining two thresholds, three groups were formed: panic disorder, subthreshold panic disorder and no-panic. These groups were compared using multinomial regression analysis, χ2 and analysis of variance.

Results. The 12-month prevalence of panic disorder was 2·2% while that of subthreshold panic disorder was 1·9%. Symptom profiles and risk indicators associated with panic disorder and subthreshold panic disorder were similar, and half of the risk indicators were more strongly associated with panic disorder than with subthreshold panic disorder. Subthreshold panic disorder occupied an intermediate position between panic disorder and no-panic with regard to the number of symptoms, the percentage of subjects with co-morbidity, and functioning.

Conclusions. Subthreshold panic disorder is common, and seems clinically relevant, but is milder than panic disorder. These results thus support the use of a double threshold in panic. Further research should focus on the positioning of the thresholds, the course of subthreshold panic disorder and its treatment options.

Prolactin, FSH, LH and TSH were determined in repeated samples of serum from 16 unmedicated male patients with chronic schizophrenia. Changes in the mental states between the 2 occasions were related to changes in hormone levels. Significant inverse correlations were established between prolactin and incoherence of speech, between prolactin and total positive symptoms and between FSH and poverty of speech. A significant positive correlation was established between FSH and delusions. These findings are discussed in the context of evidence concerning the role of monoamines in the control of anterior pituitary function, and of the dopamine and other monoamine hypotheses of schizophrenia. Although prolactin secretion was not as low, as would be predicted on the basis of the dopamine overactivity hypothesis of schizophrenia, the relationship between symptom change and change in prolactin secretion was consistent with the hypothesis that increasing symptom severity is associated with increasing dopamine release from the tubero-infundibular system.

Background. Reduced serotonin (5-HT) function and deficits on neuropsychological tasks have been separately reported in antisocial populations. We investigated whether these impairments are independent or associated factors underlying impulsivity in aggressive personality disordered (PD) offenders and healthy controls and whether there are associated changes in quantitative brain measures.

Methods. This study reports on the findings from a sample of 51 PD offenders and 24 controls, recruited from maximum security psychiatric hospitals, who were characterized using the Special Hospital Assessment of Personality and Socialisation (SHAPS). Subjects underwent assessment of 5-HT function (prolactin response to D-fenfluramine challenge), neuropsychological testing and had a diagnostic MRI scan. Of this sample 19 controls and 24 patients also had quantitative measurement of frontal and temporal lobe volumes on magnetic resonance imaging (MRI).

Results. Non-psychopathic (low-impulsive) aggressive PDs had enhanced 5-HT function compared with controls and highly impulsive aggressive psychopaths. Primary and secondary psychopaths had poorer executive/frontal, but not memory/temporal neuropsychological function than controls and non-psychopaths. There were no significant group differences in frontal or temporal lobe brain volumes. Although impulsivity and aggression are correlated constructs impulsivity appeared to be related to both executive function and 5-HT function, while aggression only correlated inversely with executive/frontal and memory/temporal function. 5-HT did not directly correlate with frontal or temporal volume or function.

Conclusion. Impulsivity appears to be contributed to by both impaired neuropsychological function and 5-HT function. Impaired neuropsychological function alone makes a contribution to aggression. Treatment needs to take account of the neuropsychological and biochemical deficits in this challenging population.

Background. Prior research suggested that time splitting – suppressing the past and dissociating it from present and future – protected refugee mental health in the aftermath of catastrophe. The current study investigates temporal reintegration, defined as cognitive recapture of the past and reconnecting it with present and future, the mental health effects of temporal reintegration, and factors moderating the associated risk for Depressive Disorder.

Method. A community sample of 608 Southeast Asian refugees, resettled in Vancouver British Columbia between 1979 and 1981, were interviewed on three separate occasions over a 10-year period. Participants performed a temporal orientation task and responded to questions about employment, social relations and mental health. Depressive Disorder, measured by a typology derived from Grade of Membership analysis of symptoms, constituted the dependent variable. Latent Growth Curve Analysis was used to examine both levels and rates of change in the probability of Depressive Disorder as predicted by changes in temporal reintegration, as well as the contribution of putative social and psychological moderators to explaining variations in growth parameters.

Results. Time relatedness increased over the duration of the study. Temporal reintegration jeopardized mental health. Employment and relational stability each moderated the mental health effects of temporal reintegration.

Conclusions. Although time splitting may be effective in coping with adversity over the short-term, eventual temporal reintegration is probably ineluctable. Stability in love and work are protective factors, mitigating the mental health vicissitudes of temporal reintegration. Implications for optimal timing of clinical interventions are discussed.

People have jumped (or fallen) in front of trains on the London Underground system in increasing numbers throughout the twentieth century. During the past decade there have been about 100 such incidents each year, of which around 90 would involve the train driver witnessing his train strike the person on the track. Most are suicides or attempts at suicide. They represent major unexpected and violent events in the lives of the train drivers and it might be expected that some of them would respond by developing a post-traumatic stress reaction of the type identified by Horowitz (1976) or other adverse psychological reactions or both. The research reported in this paper was designed to characterize the range of responses of drivers to the experiences of killing or injuring members of the public during the course of their daily work. It was found that 16·3% of the drivers involved in incidents did develop post-traumatic stress disorder and that other diagnoses, e.g. depression and phobic states, were present in 39·5% of drivers when interviewed one month after the incident.

On the basis of data derived from a long-term follow-up of 12 cases and a 2-year follow-up of the International Pilot Study of Schizophrenia it is suggested that some patients with remitting schizophrenic illnesses can subsequently present clear-cut affective disorders. The implications of these findings are discussed.

Several studies have suggested that ‘anomalous parenting’, as measured by the Parental Bonding Instrument (PBI), may be a differential risk factor to subsequent depression in adulthood – being irrelevant to melancholia but over-represented in non-melancholic depressive disorders. Such a ‘specificity’ effect is confirmed in our current sample of 65 melancholic and 84 non-melancholic depressed patients. Secondly, we examine the risk to depression effected by exposure to one parent with an anomalous parental style, and the extent to which that risk is modified by characteristics of the other parent. We find clear evidence of additive effects with the risk to non-melancholic depression being raised by exposure to ‘anomalous parenting’ from two parents. Of the varying parental styles measured by the PBI, low parental care from both parents provided the highest risk to non-melancholic depression (being 4–7 time higher in one sample and 13–27 times higher in the other).

Background. We investigated whether there is regional variation in the incidence of schizophrenia and if so, whether it is caused by urban–rural differences, larger spatial clustering, or both. To control for the effect of migration, we examined regional variation in the incidence according to place of birth.

Methods. Finnish birth cohorts born from 1950 to 1969 were followed in the National Hospital Discharge Register from 1969 until 1991, and all cases of schizophrenia (ICD-8 or ICD-9 295) were identified (N = 14828). Forty-eight of the 559 municipalities were classified as urban and 25% of the Finnish population lived in these municipalities in 1960. For the analysis of spatial clustering, municipalities were grouped into 57 functional small-areas. We used Poisson regression model with the number of births of individuals who later developed schizophrenia as a response variable, and place of birth (urban/rural), birth cohort (1950–54, 1955–9, 1960–64, and 1965–9), functional small-area units, and sex as response variables.

Results. The incidence was slightly higher among the rural-born in the oldest birth cohort. In the other cohorts, it was higher among the urban-born, and the difference between urban and rural born increased in the youngest cohorts. Significant spatial clustering of schizophrenia was observed in eastern Finland.

Conclusions. Urban birth is a risk factor for schizophrenia in Finland in cohorts born since 1955. However, genuine spatial clustering of schizophrenia in eastern Finland was also observed, possibly caused by genetic isolation.

This review will start by considering studies of the genetic contribution to the liability to depression, and go on to consider some of the ways in which environmental factors can modify gene expression. This will lead on to the pathways by which the genetic factors also appear to control stressful life events in adolescence and adult life, and then to a consideration of causes that are entirely environmental. We will conclude by considering the causes of the gender differences in the prevalence of depression during adult life.

This review collates evidence of substantial physical morbidity in patients who receive psychotropic drugs, and evidence that these drugs are not infrequently prescribed for patients with known physical illness. Minor tranquillizers are the psychotropic drugs most commonly prescribed, and the category of physical illness most likely to be associated with psychotropic medication is cardiovascular disease.