Background. Comparatively little is known about the long-term natural history of depressive disorders in the elderly living in the community. This is a follow-up of a subsample of the Continuing Health in the Community study random sample of the elderly population living in Liverpool.

Methods. The investigators followed up 120 cases of depression identified by a semi-structured interview schedule (GMS) for a period of 5 years. A similar number of other subjects defined as subcases of depression, other cases of mental illness and a random selection of non-cases were also included.

Results. The 5-year outcome for the cases of depression was worse than the outcome of the non-cases (relative mortality risk of 2·1, 95% confidence interval 1·1 to 3·9). Thirty-four per cent of the cases of depression died and 28% had dropped out during the follow-up. Of the 46 cases of depression who had a complete follow-up, 22% recovered from their symptoms, 30% were found to be AGECAT cases at one of the three follow-up waves, 24% were AGECAT cases at two of the three follow-up waves and the remaining 24% were AGECAT cases at each follow-up wave. Fifteen per cent of the surviving cases of depression were organic cases at the follow-up. Their anxiety co-morbid state and depression score were identified as predictors of poor outcome.

Conclusion. The findings of this study indicate that depressive disorders (most of which were untreated) found in the elderly community have a poor prognosis.

Thirty-one (43%) of 68 patients with primary depression were found to have a blunted thyroid-stimulating hormone (TSH) response to thyrotropin-releasing hormone (TRH). Increased thyroid activity, as measured by the free thyroxine index (FTI), was present in 16 (24%) of the patients. Patients with blunted responses had a higher mean FTI level than those with normal responses. Patients with blunted responses were significantly more likely to exhibit the symptoms of depersonalization, derealization and agitation. There was no clear association between blunting and any particular diagnostic category of depression.

Patients with blunted responses and high FTI values were more likely to report significant long-term environmental difficulties than patients with blunted responses and normal FTI values. It is suggested that there may be more than one mechanism responsible for blunting of the TSH response in depressed patients. In some patients blunting may be due to negative feedback from increased output of thyroid hormones, possibly released as part of a stress response. In other patients blunting may be due to a different mechanism, possibly involving pituitary gland dysfunction. These mechanisms would not necessarily be mutually exclusive in any one patient.

Background. Prior population-based twin studies from two Anglophonic countries with relatively high rates of drug use – the USA and Australia – suggest that genetic factors contribute substantially to individual differences in the use, abuse and dependence of illicit psychoactive substances. Would these results replicate in Norway, a Nordic country with a low prevalence of illicit drug use?

Method. Lifetime use, abuse and dependence of five illicit drug categories (cannabis, stimulants, opiates, cocaine and psychedelics) were assessed at personal interview in 1386 complete young adult twin pairs ascertained from the Norwegian Institute of Public Health Twin Panel. Twin model fitting was performed using the Mx statistical package on three phenotypes: any lifetime use, endorsement of at least one DSM-IV symptom of abuse or dependence, and meeting DSM-IV criteria for abuse or dependence.

Results. Significant lifetime use of illicit substances (defined as use 10 or more times) was reported by only 6·4% of the sample. Meaningful analyses were possible for use of any substance and each of the five substances individually, but for symptoms or a diagnosis of abuse/dependence meaningful analyses were possible only for any substance and cannabis. Full twin models uniformly found twin resemblance to be due largely or entirely to genetic factors. Best-fit models for all analyses included only genetic and individual-specific environmental effects with heritability estimates ranging from 58% to 81%.

Conclusion. In accord with prior results from the USA and Australia, genetic factors appear to play an important role in the etiology of use and abuse/dependence of illicit drugs in Norway.

One hundred and seven unrelated Danish patients considered to be manic-depressive according to strict diagnostic, symptomatic and course criteria were typed for antigens of the HLA system, the major histocompatibility system in man. Preliminary results from the first 47 patients had previously been reported to suggest a positive association between manic-depressive disorders and HLA-A3, HLA-B7, and HLA-Bw16 and a negative association between such disorders and HLA-B8. Results from the extended series provide confirmatory evidence that there is a positive association between manic-depressive disorders and HLA-Bw16 and also strongly suggest a positive association between HLA-B7 and such disorders. HLA typing may prove to be a useful way of identifying sub-groups of manic-depressive patients for other biological studies. The associations described provide a potential lead for formulating hypotheses about the nature of the biological mechanisms which predispose to manic-depressive disorders.

Background. This paper seeks to explain an excess of psychological distress previously found among groups of British South Asians (with ancestry from the Indian subcontinent) living in Glasgow, compared with the general population. The excess was found on a psychosomatic measure and a measure of self-assessed distress but not on a clinically validated measure (the General Health Questionnaire or GHQ). The paper investigates whether South Asians are subject to stressful situations to which the GHQ is less sensitive than the other two measures.

Methods. Random samples of 159 South Asians aged 30–40, mean age 35, and 319 from the general population, all aged 35, were interviewed in Glasgow, using the 12-item General Health Questionnaire (GHQ-12), a psychosomatic symptom scale (PSS) and a self-assessment of distress. Subcultural groupings were differentiated by South Asian origin, English fluency, religion, and gender. Stressful situations assessed were experience of assault, stress/dissatisfaction with work, overcrowding, low standard of living, absence of family and absence of confidants.

Results. The GHQ-12 was less sensitive to certain stressful situations than the other two measures. The PSS and/or self-assessed distress were more sensitive to low standard of living, self-rated stress in work around the house and possibly experience of assault. In a combined analysis, the relation between distress on the PSS or self-assessed measure and subcultural groupings became non-significant, while the relation between distress and key stressful situations remained significant.

Conclusions. The greater distress of women, Muslims and limited English speakers is largely explained by the stressful situations they experience. The GHQ-12 under-estimates distress related to situations experienced particularly by ethnic minorities and by women.

Chronic fatigue syndrome (CFS) is characterized by severe and prolonged fatigue, affecting both physical and mental functioning, exacerbated by relatively minor exertion (Fukuda et al. 1994). A variety of other symptoms such as impaired concentration and memory, disturbed sleep, depressed mood and anxiety are also often present. Alongside this emerging consensus describing the clinical features of chronic fatigue, controversy has raged as to its aetiology, particularly the relative importance of viruses and other infectious agents, the contribution of neuromuscular abnormalities and whether the association with psychiatric disorders is primary or secondary.

Background. To date, there is little information about how severely burned patients compare to unburned healthy individuals in terms of psychological profile and quality of life. As part of a larger study on the sensory consequences of burns, we assessed psychological functioning and quality of life in burned patients and unburned healthy control subjects. We also examined whether burn patients experiencing pain and/or paresthetic sensations (i.e. symptomatic patients) present a profile that is different from those who are asymptomatic.

Methods. Forty-nine burned patients (% total body surface area = 34·59%±13·40; 82% males/18% females) were evaluated 63·59±28·1 months post-burn. They were matched with 49 unburned healthy volunteers on age, sex, and education level. All subjects were administered the Symptom Checklist 90-Revised (SCL-90-R) to assess psychological functioning and the 36-item Short-Form Health Survey (SF-36) to assess quality of life.

Results. Approximately 25% of the burn patients presented clinically-significant psychological disturbances compared to 12% in the control group. Burn patients enjoyed a quality of life comparable to that of the control subjects, although they perceived some deterioration in their general health. More symptomatic than asymptomatic patients suffered from clinically-relevant somatization and obsessive–compulsive disturbances.

Conclusions. Severely burned patients adjust relatively well, although some develop clinically-significant psychological disturbances such as somatization and phobic anxiety. Burn patients experiencing abnormal sensations in their healed wounds (i.e. symptomatic patients) do not suffer from maladjustment to a greater extent than their asymptomatic counterparts, although more symptomatic patients experience somatization and obsessive–compulsive behaviours.

Background. This and the companion paper present two sequential family studies of obsessive–compulsive disorder (OCD) conducted by the same research group, but with different sampling and best-estimate procedures. In addition to providing further data on familial transmission of OCD, we used comparison of disparate findings (moderate, specific familial aggregation in this first study versus a stronger effect for other anxiety disorders than for OCD alone in the second) to examine possible effects of proband characteristics and informant data on outcome.

Method. In this initial study we interviewed 179 first-degree relatives of 72 OCD probands and 112 relatives of 32 never mentally ill (NMI) controls. Informant data were obtained on an additional 126 relatives (total ‘combined’ samples of 263 and 154 respectively). Analyses used best-estimate diagnoses made by consensus of two ‘blinded’ senior clinicians who reviewed all diagnostic materials including proband informant data about relatives.

Results. Significantly higher risk for OCD but not other anxiety disorders was found in relatives of OCD probands compared to relatives of controls in both the directly interviewed and combined samples. There was no relationship between proband age at onset of OCD and strength of familial aggregation.

Conclusions. These data indicate moderate familial aggregation of OCD, but do not support increased transmission by early onset probands, or a familial relationship between OCD and other anxiety disorders with the possible exception of generalized anxiety disorder.

Background. Sertraline has a proved efficacy in post-traumatic stress disorder (PTSD), but it is unknown which symptoms respond or in what sequence this occurs. Such information might be useful clinically and heuristically.

Method. The study examined the effects of sertraline on the individual symptoms of PTSD. It also examined whether early changes in anger explained drug-induced change in other symptoms over time. Mixed models analysis was applied to datasets from two 12-week placebo-controlled trials of sertraline. A validated self-rating scale (DTS) was used to assess treatment efficacy.

Results. Sertraline was superior to placebo on 15 of 17 symptoms, especially in the numbing and hyperarousal clusters. A strong effect was found on anger from week 1, which partly explained the subsequent effects of sertraline on other symptoms, some of which began to show significantly greater response to drug than to placebo at week 6 (emotional upset at reminders, anhedonia, detachment, numbness, hypervigilance) and week 10 (avoidance of activities, foreshortened future).

Conclusions. Sertraline exercises a broad spectrum effect in PTSD. Effects are more apparent on the psychological rather than somatic symptoms of PTSD, with an early modulation of anger and, perhaps, other affects, preceding improvement in other symptoms.

Background. A limited number of studies have assessed the pathways to care of patients with first-episode psychosis. The aim of the study was to describe the pathways to care of subjects with psychosis between onset of psychosis and first admission, and to examine the demographic and clinical factors influencing access to care.

Method. Number and type of helping contacts since onset of first psychotic symptoms were assessed using multiple sources of information in 86 subjects with psychosis first-admitted in two hospitals of South-Western France. Characteristics independently associated with long delays between onset of symptoms and first helping contact, first treatment and first admission were explored using logistic regressions.

Results. Twelve per cent of subjects were first admitted without any previous helping contact. The patients were seen by a median of two helpers (maximum 7). For most patients (70%), the first helping contact was a health care professional, and the same proportion of patients had a first contact with a GP or a psychiatrist. The type of first contact was not predicted by demographic or clinical characteristics. Subjects with poor pre-morbid functioning or at-risk behaviour were more likely to have a delayed access to care.

Conclusions. The delay in access to care may not be totally attributed to inadequate management by health professionals, but may be a characteristic of the disease itself, at least in part independent of the organization of the health system.

This survey investigates drug defaulting by schizophrenic patients on a regime of long-term medication with injections of long-acting phenothiazines (LAP). Although the frequency of discontinuing LAP was appreciably less than reported in most surveys on oral medication, it remained a problem. An analysis of the reasons for patients discontinuing LAP identified several causes: patient-refusal, side-effects, failure of administration of the regime, and patients losing contact with the medical services by moving to other districts.