In a randomized, controlled trial neurotic patients (mainly phobics and obsessive-compulsives) in primary care were assigned to behavioural psychotherapy from a nurse therapist or to routine care from their general practitioner. At the end of one year clinical outcome was significantly better in patients cared for by the nurse therapist. Economic outcome to one year, compared with the year before entering the trial, showed a slight decrease in the use of resources by the nurse therapist group (N = 22), and an increase in resource usage in the GP-treated group (N = 28), mainly due to the letter's increased absence from work and more hospital treatment and drugs. On the reasonable assumptions that nurse therapists treat 46 patients a year and that such patients treated behaviourally maintain their gains for 2 years, the economic benefits to society from nurse therapists treating such patients may outweigh the costs. This excludes any monetary value on the substantial clinical gains such as reduction in fear and anxiety. However, the numbers are small, few economic differences were significant, and many patients either did not complete the trial or waiting-list periods or they failed to return economic data. Conclusions must thus be tempered with caution, even though pre-treatment demographic and clinical data of non-returners were comparable with those of returners, and though the few drop-outs who could be rated at one year had not improved. The findings cannot be extrapolated to other types of clinical problem and treatment.

Caffeine toxicity remains a rarely reported condition, which may mimic anxiety disorders. Anxiety disorder patients do not consume toxic amounts of caffeine. However, increased sensitivity to caffeine in these patients has been suggested as contributing to their symptoms. Six cases of anxiety disorder are presented who improved with only caffeine abstention, and remained well for at least a six-month follow-up period.

This study is an attempt to demonstrate confabulation in schizophrenia. Twelve patients who met DSM-III-R criteria for schizophrenia were matched for age, sex and pre-morbid IQ with 12 volunteers, 9 of whom were normal healthy subjects, with the remainder being depressed patients. To elicit confabulation, subjects were asked to recall narratives. In addition, subjects were examined on a number of neuropsychological tests. Confabulation was denned as recall of information not present in the narrative. Variable amounts of confabulation were observed in all schizophrenics, while only one control subject confabulated. The content and structure of their productions differed from previously reported forms of confabulation in that schizophrenic patients spontaneously rearranged the original narratives to produce new ideas. The amount of confabulation was found to be related to difficulties in suppressing inappropriate responses (Hayling test) and formal thought disorder, but unrelated to understanding of the gist or moral of the narratives. Tentative mechanisms for the process of confabulation are proposed, based on specific difficulties with comprehension, response monitoring and response suppression.

Two random samples, each constituting 0·5 % of the institutionalized elderly (over 65) in the cities of New York and London have been compared. This preliminary report of a collaborative study demonstrates the similarity of the 2 samples.

Institutions in the 2 cities are shown to differ in size, type of ownership and the frequency that skilled nursing is provided.

Some implications of these 2 findings are raised now, and will be discussed later when the full data for the study are presented.

Background. Autism is a neurodevelopmental disorder associated with slight increases in brain volume. There has been some suggestion that medial temporal lobe structures may be preferentially involved in this disorder, although results have not always been consistent. Here, we investigate amygdala and hippocampus volumes in medication-naive subjects with high-functioning autism.

Method. Whole-brain magnetic resonance imaging scans were acquired from 42 patients and 42 closely matched, healthy control subjects.

Results. Amygdala volume did not differ significantly between patients and controls. A significant increase in hippocampal volume was proportional to an increase in overall brain volume.

Conclusions. These results argue against preferential involvement of medial temporal lobe structures in autism, at least in high-functioning medication-naive individuals.

This paper describes a modified version of the MRC Needs for Care Schedule (the Cardinal Needs Schedule), for measuring needs for psychiatric and social care amongst patients with severe psychiatric disorders. The modified schedule has three new features: (i) it is quick and easy to use; (ii) it takes systematic account of the views of patients and their carers; (iii) it defines and identifies need in a way that is concise and easy to interpret. The paper describes why the three new features were considered necessary, and then gives an overview of the structure of the Cardinal Needs Schedule, together with a description of how the three new features were developed. During a study of social services care management the practicality of the modified schedule was investigated and further data were obtained on the reliability and validity of the standardized approach to measuring need, in domains not previously investigated. Because of its speed and simplicity, the Cardinal Needs Schedule offers a new choice to researchers who wish to use a standardized and practical assessment of need in evaluative studies of community care. Examples of the usage of the modified schedule are given in an Appendix.

Background. While high levels of social support (SS) are associated with a decreased risk for major depression (MD) or less depressive symptomatology, and stressful life events (SLEs) have a substantial causal relationship with MD, uncertainty remains as to whether a main-effect or a buffering model best explains the nature of the relationship among SS, MD and SLEs.

Method. Using two waves of interview data on 2163 female twin pairs from a population-based twin registry, and discrete time survival analysis with both logistic and linear regression models, we examine the ability of interactions between eight dimensions of SS and 16 categories of stressful life events to predict MD onset and levels of depressive symptomatology.

Results. In the presence of a significant effect of a SLE on MD (β [ges ] 1·00), we found evidence for seven interactions out of a possible 93, of which none involved buffering effects. Similarly, examination of depressive symptomatology detected a total of two interactions (both buffering) out of possible 28. We found no evidence, beyond what would be expected by chance, for the existence of buffering effects where either MD or depressive symptomatology was used as the dependent variable.

Conclusions. There is little evidence to suggest the presence of the buffering effect of social support in the face of adverse life events for women. We suggest that it is important to use alternative models (multiplicative and additive) to examine data, to investigate the match between stressors and social resources, and to investigate fully whether detected interactions actually represent a buffering effect.

Background. The purpose of this study was to assess clinical characteristics, including co-morbid personality disorders in patients with both anorexia nervosa (AN) and obsessive–compulsive disorder (OCD) in comparison with age- and sex-matched patients with OCD.

Methods. Fifty-three female patients with AN were divided into two groups based on the presence or absence of a current diagnosis of OCD, as assessed by the Structured Clinical Interview for DSM-III-R Patient version (SCID-P). Twenty-one women (40%) who met the DSM-III-R criteria for both AN and OCD were compared with 23 female patients with OCD, using the Yale-Brown Obsessive Compulsive Scale (Y-BOCS) and the SCID Axis II disorders.

Results. There were no significant differences on the mean Y-BOCS severity scores between these groups. However, AN patients with OCD were significantly more likely than OCD patients to have obsessions with need for symmetry or exactness and ordering/arranging compulsions, whereas both aggressive obsessions and checking compulsions tended to be more frequently identified in OCD patients compared with AN patients with OCD. AN patients with OCD were significantly more likely than OCD patients to meet the criteria for obsessive–compulsive personality disorder (OCPD).

Conclusions. These results suggest that there are some differential characteristics of the OCD symptomatology between these disorders, although many patients with AN manifest significant impairment from primary OCD symptoms with similar magnitude in severity to that found in OCD patients.

Background. Dysregulation of corticotropin (ACTH) and cortisol response after corticotropin-releasing hormone (CRH) stimulation has been reported in bipolar patients. Most findings involve the pathophysiology of the depressive phase of the illness and its prediction. However, the possible predictive value of the CRH challenge test with respect to manic episodes remains unknown.

Methods. The ACTH and free cortisol response to the injection of 100 μg of synthetic human CRH and plasma cortisol-binding globulin levels were measured in 42 lithium-treated patients suffering from Research Diagnostic Criteria bipolar I disorder in remission, and 21 age- and sex-matched normal controls. A 1-year follow-up was conducted to assess any possible relationship between outcome and the hormonal response.

Results. Bipolar patients showed higher baseline and peak ACTH concentrations than control subjects. A higher area under ACTH concentration curve after CRH stimulation predicted manic/hypomanic relapse within 6 months by multiple regression analysis.

Conclusion. Bipolar patients in remission show mild abnormalities in ACTH levels before and after CRH stimulation. CRH challenge may be a potentially good predictor of manic or hypomanic relapse in remitted bipolar patients.

There is now a considerable body of epidemiological evidence from developing countries and multilateral agencies that so called common mental disorders are common and disabling (e.g. Murray & Lopez, 1996; Patel et al. 1998). The logical next step is to identify efficacious and cost-effective health services interventions that can tackle the all-important ‘so-what’ question that is posed by doctors and policy makers in developing countries when confronted with startling prevalence statistics. The rise of evidence-based medicine has highlighted the need for quality trials that can inform and guide clinical practice. This editorial poses the question of whether we need treatment evidence from developing countries. The key issue is whether we can assume that psychiatric treatment evidence can be applied from one culture, or region, to another. If, for example, this was possible, then clinical practice in developing countries could be fairly well informed by trials conducted in the West. However, there are several factors that limit the cross-cultural applicability of treatment research in psychiatry.

Background. The prescription of antidepressants has increased substantially over the last 10 years. It is therefore timely to examine trends in mortality associated with overdoses of antidepressants and to compare the relative mortality associated with different antidepressants.

Methods. Data were derived from a newly developed national database of deaths from overdose and poisoning in England and Wales between 1993 and 1997. Age and sex specific death rates associated with overdose and poisoning with antidepressants were calculated together with numbers of deaths per 100000 prescriptions of individual antidepressants.

Results. Twenty per cent (2503) of all deaths from overdose or poisoning were antidepressant related. The number of deaths increased by 18% between 1993 and 1997. Ninety-five per cent of deaths from antidepressants were associated with tricyclic antidepressants, particularly dothiepin and amitriptyline. Tricyclic antidepressants were associated with 5·3 deaths per 100000 prescriptions, 4·4 for monoamine oxidase inhibitors and 0·4 for selective serotonin reuptake inhibitors. Annual death rates were highest in men aged 30–44 years (18·2 per million) and women aged 45–59 years (14·8). Death rates from antidepressants were 2·5 times higher in the most deprived fifth than in the least deprived fifth of enumeration districts.

Conclusions. Antidepressants are an important cause of death from poisoning and overdose. SSRIs and newer antidepressants are associated with <10% of the risk of death than the older antidepressants. There is a strong association between area deprivation and deaths from antidepressants.