Background. Causal, responsibility and blame attributions for positive and negative symptom behaviours were examined in 70 caregivers of persons with schizophrenia.

Methods. The majority of subjects belonged to self-help group organizations. The three types of attributions for positive and negative symptom behaviours were assessed by self-report questionnaires.

Results. The extent of patient responsibility did not differ between the two types behaviours. Intentionality and knowledge were equally important in predicting responsibility for positive symptom behaviours, while intent was the most important predictor of responsibility for negative symptom behaviours with the patient capacity playing a significant but minor role. The entailment model was not supported for the two types of behaviours.

Conclusions. Increased attention should be given to responsibility dimensions in assigning moral accountability to the patient. The entailment model should be further explored in problematical caregiving situations.

Background. In a number of theories of compulsive drug use conditioned responses to stimuli associated with drug taking play a pivotal role. For example, according to incentive-sensitization theory (Robinson & Berridge, 1993), drug-related stimuli selectively capture attention, and the neural mechanisms underlying this attentional bias play a key role in the development and maintenance of drug dependence, and in relapse. However, there has been little work that assesses attentional biases in addiction.

Methods. We used a pictorial probe detection task to investigate whether there is an attentional bias to stimuli associated with drug use in opiate dependence. Stimuli presented included pairs of drug-related and matched neutral pictures. Methadone-maintained opiate addicts (N = 16) were compared with age-matched controls (N = 16).

Results. A mixed design analysis of variance of response times to probes revealed a significant three-way interaction of group×drug picture location×probe location. Opiate addicts had relatively faster reaction times to probes that replaced drug pictures rather than neutral pictures, consistent with the predicted attentional bias to drug-related stimuli.

Conclusions. These results support the idea that an attentional bias for drug-related stimuli occurs in opiate dependence. This is consistent with the concept of a central role for such salient stimuli in compulsive drug use.

Background. The incidence of deliberate self-harm (DSH) in Britain has increased markedly over the last 30 years. Reasons for this rise are not clear. We have investigated whether changes in the social and economic environment underlie any of the recent increase in DSH incidence.

Methods. An ecological analysis was used to assess associations between changes in census-based measures of the social and economic environment – the Townsend Deprivation Index and a three-factor social fragmentation index – and changes in age- and sex-specific hospital attendance rates for DSH for the 28 wards of the city of Bristol between 1972–3 and 1995–6.

Results. There were significant cross-sectional associations between the Townsend Index and rates of DSH in both males and females in both time periods. Increases in Townsend Index were also associated with increases in DSH. This association was statistically significant at the 5% level in 25–34 year-old females. Associations with the social fragmentation index were weak, although our index was based on rather limited data.

Conclusions. This analysis suggests that changes in levels of socio-economic deprivation may influence area-specific patterns of DSH and such changes may have contributed to recent rises in DSH.

Background. Although it is well recognized that individuals with schizophrenia display evidence of subtle neurological impairment, its aetiopathological and clinical significance continues to be unclear.

Methods. Patients presenting with a first episode of schizophrenia or schizophreniform psychosis (DSM-IV criteria) were examined using two previously validated neurological examinations. The majority (N = 35) were examined prior to their ‘first ever’ dose of neuroleptic while the remaining patients (N = 21) had been medicated for less than one month. The manner in which neurological functioning is influenced by symptomatology and handedness was ascertained.

Results. The majority of patients who were examined neuroleptic-naive displayed evidence of neurodysfunction. A combination of relative hand preference and symptomatology explained a significant proportion of the variance in neurological functioning. Mixed handedness among adults at the time of first presentation with schizophrenia was associated with more severe neurological impairment and a history of poorer scholastic attainment and pre-morbid social adjustment.

Conclusions. Neurological soft signs are an intrinsic part of schizophrenia rather than a direct consequence of treatment. Early developmental processes are associated with the level of subsequent neurological impairment in first episode schizophrenia. However, symptomatology appears to have an influence on the apparent severity of neurological impairment.

Background. Chronic fatigue syndrome (CFS) and major depressive disorder (MDD) share many symptoms and aetiological factors but may have different neurobiological underpinnings. We wished to determine the profile of the biological variables disturbed in CFS and MDD, and identify any critical factors that differentiate the disorders.

Methods. Thirty patients with CFS, 20 with MDD and 15 healthy controls – matched group-wise for age and sex – were recruited. Subjects were given a detailed battery of motor and cognitive tests, including measures of psychomotor speed, memory and maximal voluntary muscle contraction in both the morning and evening that were balanced to avoid order effects.

Results. CFS patients generally performed worse on cognitive tests than healthy controls, but better than patients with MDD. Both patient groups had markedly impaired motor function compared with healthy controls. MDD subjects showed a significantly greater diurnal improvement in maximal voluntary contraction than healthy controls.

Conclusions. Patients with CFS and MDD show similarly substantial motor impairment, but cognitive deficits are generally more marked in MDD. Diurnal changes in some functions in MDD may differentiate the disorder from CFS.

Background. While neuropsychological dysfunction is common in geriatric depression, not all aspects of cognition are equally affected. It has been suggested that depressed patients are impaired only in tasks that make heavy demands on processing resources and that a resource decrement therefore underlies the neuropsychological decrements seen in geriatric depression. The present study examined whether processing resources in the form of working memory and information processing speed are decreased in depression and whether a decrease in these resources actually mediates neuropsychological impairment.

Methods. Measures of processing resources were administered to elderly depressed patients prior to treatment and to age-matched controls. Patients whose depression remitted were retested as were the controls. Subjects also received neuropsychological tests of episodic memory and visuospatial performance.

Results. Depressed patients performed significantly worse on measures of both processing speed and working memory. While performance on these measures improved in patients whose depression remitted, the amount of improvement was no greater than that seen in the controls with repeat testing. Hierarchical regression analyses showed that depression explained a significant amount of variance on the neuropsychological tasks. However, if the variance associated with processing resources was removed first, depression no longer accounted for a significant amount of neuropsychological variance.

Conclusions. Processing resources are decreased in elderly depressed patients and this decrease in resources appears to mediate impairments in several areas of neuropsychological functioning including episodic memory and visuospatial performance. The resource decrement persists after remission of the depression and thus may be a trait marker of geriatric depression.

Background. Indicators of population socio-economic disadvantage expressed as weighted deprivation indices show strong relationships with mental health and underpin national funding of psychiatric services. A new index of social deprivation, the Mental Illness Needs Index, has been devised specifically to predict need for psychiatric services. Its validity has not been established outside the area in which it was developed.

Methods. We explored the relationship between the Mental Illness Needs Index and two alternative indicators of need for mental health services: the prevalence of psychiatric admission for electoral wards in Nottingham (calculated from Hospital Episode Statistics for the years 1992 and 1993) and ward-based incidence rates for psychosis (ICD-10 F1X-F33). Relationships were explored graphically using local regression models, and estimated using Generalized Linear and Additive Models, and Poisson regression.

Results. Social deprivation was strongly related to admission prevalence and psychosis incidence (Spearman's rho 0·63 and 0·44 respectively). Neither admission prevalence, nor the incidence of psychosis were linearly related to social deprivation. Areas with above average social deprivation had both more new cases of psychoses and a higher proportion of the population admitted than expected from a linear function.

Conclusions. Application of a linear function to funding gradients may underfund high and low need areas and overfund median need areas. Improving the precision of estimates of the relationship between social deprivation and need for services is crucial to more equitable resource allocation.

Background. Increased recall of categorical autobiographical memories is a phenomenon unique to depression and post-traumatic stress disorder, and is associated with a poor prognosis for depression. Although the elevated recall of categorical memories does not change on remission from depression, recent findings suggest that overgeneral memory may be reduced by cognitive interventions and maintained by rumination. This study tested whether cognitive manipulations could influence the recall of categorical memories in dysphoric participants.

Methods. Forty-eight dysphoric and depressed participants were randomly allocated to rumination or distraction conditions. Before and after the manipulation, participants completed the Autobiographical Memory Test, a standard measure of overgeneral memory. Participants were then randomized to either a ‘decentring’ question (Socratic questions designed to facilitate viewing moods within a wider perspective) or a control question condition, before completing the Autobiographical Memory Test again.

Results. Distraction produced significantly greater decreases in the proportion of memories retrieved that were categorical than rumination. Decentring questions produced significantly greater decreases in the proportion of memories retrieved that were categorical than control questions, with this effect independent of the prior manipulation.

Conclusions. Elevated categorical memory in depression is more modifiable than has been previously assumed; it may reflect the dynamic maintenance of a cognitive style that can be interrupted by brief cognitive interventions.

Background. Self-report data obtained from members of advocate groups for patients with anxiety or mood disorders in 11 countries were used to study time to initial professional help-seeking after incident episodes.

Method. Data were taken from 3516 self-administered questionnaires completed by members of GAMIAN, an international consortium of mental health patient advocate groups. Reports about age at onset and age at first seeking treatment were obtained retrospectively.

Results. Approximately 40% of respondents reported that they sought treatment in the same year as the first onset of their disorder. The median delay in help-seeking was 8 years for the remainder of respondents. Synthetic cohort analysis suggests that delays have decreased in recent cohorts. However, time to initial help-seeking in all cohorts and all countries was found to be inversely related to age at onset.

Conclusions. Although caution is needed in generalizing the results beyond members of patient advocate groups, the key patterns found here were also found in previous analyses of general population surveys carried out in the US and Canada. The critical and consistent finding in all these studies is that presumably curable adolescents with early-onset disorders are, in effect, ignored by the treatment system in these countries. Aggressive outreach and intervention among early-onset cases might prove to be a cost-effective approach both to prevent the onset of secondary disorders and to improve success in treating primary disorders.

Background. Hip fracture is common in the elderly. Previous studies suggest that psychiatric illness is common and predicts poor outcome, but have methodological weaknesses. Further studies are required to address this important issue.

Methods. We prospectively recruited 731 elderly participants with hip fracture in two Leeds hospitals. Psychiatric diagnosis was made within 5 days of surgery using the Geriatric Mental State schedule and other standardized instruments, and data on confounding factors was collected. Main study outcomes were length of hospital stay, and mortality over 6 months after fracture.

Results. Fifty-five per cent of participants had cognitive impairment (dementia in 40% and delirium in 15%), 13% had a depressive disorder, 2% had alcohol misuse and 2% had other psychiatric diagnoses. Participants were likely to remain in hospital longer if they suffered from dementia, delirium or depression. The relative risks of mortality over 6 months after hip fracture were increased in dementia and delirium, but not in depression.

Conclusions. Psychiatric illness is common after hip fracture, and has significant effects on important outcomes. This suggests a need for randomized, controlled trials of psychiatric interventions in the elderly hip fracture population.

Background. While numerous studies have found disturbances in the Event-Related Potentials (ERPs) of patients with schizophrenia linked to task relevant target stimuli (most notably a reduction in P300 amplitude), few have examined ERPs to task irrelevant non-targets. We hypothesize, from current models of dysfunction in information processing in schizophrenia, that there will be less difference between ERPs to targets and non-targets in patients with schizophrenia than in controls.

Methods. EEGs were recorded for 40 subjects with schizophrenia and 40 age and sex matched controls during an auditory oddball reaction time task. ERPs to the targets and non-targets immediately preceding the targets were averaged separately.

Results. There was a disturbance in ERPs to targets but also to non-targets (reduced N100 amplitude and earlier P200 latency) and the difference between target and non-target ERP components (N100 and P200 amplitude and P200 latency), was significantly reduced in the schizophrenic group compared with controls.

Conclusions. These findings suggest a disturbance in processing task relevant and irrelevant stimuli, consistent with Gray's (1998) hypothesis of misattributions in the ‘match[ratio ]mismatch’ of novel (target) and familiar (non-target) sensory input compared with stored information.

Background. While there is considerable evidence of a high prevalence of psychiatric disorder among homeless youth, much less is known about its long-term course or the impact it may have on accommodation outcomes.

Method. A random sample of 161 homeless people 16–21 years of age were recruited from consecutive attendees at two of London's largest facilities for homeless young people. These young people were traced and re-interviewed a year later to examine accommodation, occupation and health outcomes.

Results. A total of 107 (67%) people were successfully re-interviewed. Psychiatric disorder was identified in 55% at follow up. Two thirds of those with a psychiatric disorder at index interview remained symptomatic at follow-up. Persistence of psychiatric disorder was associated with adverse childhood experiences and rough sleeping. Satisfactory accommodation outcomes were achieved by 45 subjects (42%). Better accommodation outcomes were associated with three variables measured at the index assessment: ethnic minority status; educational achievement; and, the presence of accommodation plans negotiated through a resettlement agency. While psychiatric disorder at index interview was not associated with accommodation outcome, persistent substance use in the follow-up year was associated with poor accommodation outcome. Over half of the young people had been involved in petty crime and just under a third had been convicted for more serious criminal activity. Offending and antisocial behaviour in the follow-up year were related to a history of conduct disorder, persistent substance abuse and poor accommodation outcomes.

Conclusions. Young homeless people are characterized by multiple social and medical needs. Successful resettlement of this population may depend upon integrated services that address problems of persisting substance use and mental illness as well as the immediate housing need.

Background. Many reports have appeared on associations between platelet monoamine oxidase (MAO) activity and susceptibility to psychiatric conditions; principally alcohol dependence but also conduct disorder, other drug use and depression. Recently, it has become apparent that MAO activity is inhibited by some component of cigarette smoke, and smokers have low platelet MAO activity. Since the prevalence of smoking is higher in many of the conditions in which MAO has been implicated, the MAO susceptibility associations may be partly, or entirely, false.

Methods. We have measured platelet MAO in 1551 subjects, recruited from the Australian NHMRC Twin Registry, who have provided information on alcohol use and dependence, smoking, conduct disorder, depression, attempted suicide, panic disorder and social phobia.

Results. Current smoking reduced platelet MAO activity in a significant and dose-related manner, with no evidence of lower MAO in ex-smokers or in non-smoking subjects with co-twins who smoked. Alcohol use and lifetime DSM-III-R alcohol dependence history were not associated with MAO activity when smoking was taken into account. Depression, panic disorder and social phobia showed no significant associations with platelet MAO activity. Subjects with a history of serious attempts at suicide had low platelet MAO activity; but although the difference from controls was as great as the reduction associated with smoking it was not significant after correction for smoking effects.

Conclusions. Although synaptic MAO activity undoubtedly plays a role in psychopathology, the concept that platelet MAO activity is a direct genetic marker of vulnerability to alcohol dependence cannot be sustained.

Background. The growing movement in many European countries towards capitation-based systems for financing mental health care has generated increasing interest in developing appropriate models capitation formulae. The aims of the study were: to detect and compare any differences in service costs between patients with different diagnoses; and to analyse the associations between patient characteristics and service costs.

Methods. All patients in contact with the South-Verona Community Mental Health Service during the last quarter of 1996 were included in the study. Clinical and service-related variables were collected at first index contact; 3 months later, patients were interviewed using the Client Services Recipient Interview. For those who completed both the clinical assessments and the services receipt schedule (N = 339), 1-year psychiatric and non-psychiatric direct care costs were calculated. Weighted backward regression analyses were performed.

Results. The most significant variables associated with psychiatric costs were: admission to hospital in the previous year; intensity and duration of previous contacts with South-Verona CMHS; being unemployed; having a diagnosis of affective disorder; and, Global Assessment of Functioning score. The final model explained 66% of the variation in costs of psychiatric care and 13% of variation in non-psychiatric medical costs.

Conclusions. The model presented in this study explains a higher degree of cost variance than previously published studies. In community-based services more resources are targeted towards the most disabled patients. Previous psychiatric history (number of admissions in the previous year and intensity of psychiatric contacts lifetime) is strongly associated with psychiatric costs.

Background. There has been growing interest in factors that might influence the prescription of psychotropic drugs in general practice.

Method. This was a multi-centre study using a two-phase stratified sampling strategy in primary care facilities from 14 different countries to determine factors associated with the prescription of psychotropic drugs.

Results. A total of 1763 consecutive GP attenders aged between 16 and 65 years of age were recruited. Although antidepressants were used more for depressive disorders and anxiolytics for patients with anxiety, the differential diagnosis was otherwise not an important factor in prescribing behaviour. Antidepressants and anxiolytics were prescribed twice as frequently in client centred clinics following a ‘personal physician model’ as opposed to non-client centred settings, where care was less personalized. The reverse was true of hypnotics (adjusted odds ratio of 0·5). General practitioners with a positive view of their undergraduate psychiatric training and who had had further postgraduate experience in the speciality were significantly less likely to prescribe medication, and if they did they were more likely to use antidepressants. Older patients were significantly more likely to be prescribed psychotropic medication. Several other patient factors emerged when individual classes of medication were considered; these included the loss of a spouse and the absence of physical ill health in the case of antidepressants, and female sex, fewer years of schooling and unemployment in the case of anxiolytics.

Conclusions. Social, health care and GP factors are at least as important as clinical features in the prescription and choice of psychotropic medication.

Background. Expressed emotion (EE) measured from relatives and informal carers has been consistently demonstrated to be associated with clinical outcome in schizophrenic patients. There have also been published studies that have investigated EE in professional carers that have suggested that the quality of the relationship between staff and patient may also be associated with patient outcomes. A large controlled trial of the effectiveness of different intensities of case management provided the opportunity to assess the association between the EE of case managers, including the quality of the relationship they had with patients under their care, and later clinical outcomes.

Method. This was a prospective naturalistic study of EE present in a case manager–patient dyad and subsequent patient outcomes. EE was assessed from the Five Minute Speech Sample (FMSS) at least 3 months after the case manager became responsible for the patient's care and a range of clinical outcomes were assessed 6 to 9 months later. Assessment of clinical outcomes was made independent and blind of the EE ratings.

Results. High EE ratings were significantly associated with individual case managers and not to symptom or illness factors. High EE was not associated with later clinical outcome, however, the positive relationship between case manager and patient was. The absence of a positive relationship was significantly associated with poorer outcomes.

Conclusions. In spite of very low face-to-face contact between case managers and patients, compared with the amount of contact patients have with their informal carers and family, aspects of staff attitudes and behaviour did influence clinical outcome. There are potential implications of these results for staff training and clinical practice.

Background. Patients who present with physical symptoms that lack an organic explanation are common, difficult to help and poorly understood. Their medical help-seeking is a form of care-eliciting behaviour and, as such, may be understandable in terms of attachment style. Adult attachment style influences functioning in relationships, and may affect help-seeking behaviour from professional carers such as the family doctor.

Method. A consecutive sample of 2042 primary-care attenders completed questionnaires on: the reason for consultation, attribution of symptoms, psychiatric distress (GHQ), somatic distress (BSI), and self-reported adult attachment style (ASQ). Their doctors rated presentations into explained physical, unexplained physical, or psychological.

Results. There is a powerful relationship between type of presentation and adult attachment style. Both abnormal attachment and level of psychiatric distress increased significantly from the explained physical group, through the unexplained physical group to the group who presented psychologically. Logistic regression models determined three explanatory variables that made significant independent contributions to presentation type: psychiatric distress, attachment style and symptom attribution.

Conclusion. Presentation to the doctor with unexplained physical symptoms is associated with both higher levels of psychiatric symptoms and abnormal attachment style when compared to presentations with organic physical symptoms. Patients who present overt psychological symptoms suffer more psychiatric distress and have more abnormal attachment than those presenting physical symptoms (either organically explained or unexplained). Models to explain these findings are discussed.

Background. The Well-being Questionnaire (W-BQ) has been designed to measure psychological well-being in people with a chronic somatic illness and is recommended by the World Health Organization for widespread use. However, studies into the factor structure of this instrument are still limited and their findings are inconsistent. This study aimed to investigate the factor structure of the Dutch version of the W-BQ.

Methods. A cross-validation design was used. A total of 1472 people with diabetes completed the W-BQ and were randomly assigned to group A or B. In group A (N = 736), exploratory factor analyses were conducted. Group B (N = 736) was split up into four subgroups of male or female patients with type 1 or type 2 diabetes. In these subgroups, confirmatory factor analyses were employed to test the model(s) developed in group A and the two models described in the literature (four-factor model with 22 items and a three-factor model with 12 items).

Results. Exploratory factor analyses yielded a three-factor model with 21 items (negative well-being, energy and positive well-being). In the subgroups of group B confirmatory factor analyses only accepted the three-factor model with 12 items. This factor solution was stable across gender, type of diabetes and level of education.

Conclusions. The best description of the factor structure of the Dutch translation of the W-BQ was given by a three-factor solution with 12 items (W-BQ12), measuring positive well-being (four items), negative well-being (four items) and energy (four items).

Background. Phobic disorder is one of the most prevalent psychiatric disorders in community populations and much attention has focused on the association of sociodemographic factors and social resources with the disorder. There has been little investigation of the more personal resources such as self-confidence, religiosity, social support and self-perceived health that may increase vulnerability.

Methods. We used a sample of 2914 community residents aged 18 or older who participated in the Duke University Epidemiologic Catchment Area Study to explore the relationship between both social and personal resources and the prevalence of DIS/DSM-III phobic disorder.

Results. The 1-month prevalence of any phobic disorder was 7·6%. In bivariate analyses, we found both race/ethnicity and gender differences in prevalence, with a higher prevalence of phobic disorder in African-Americans and females. Lower socio-economic status, rural residence and unmarried status were also associated with current prevalence. No association was found for social network and social interaction. Impaired subjective social support, low self-confidence, perceived poorer physical health and co-morbid psychiatric disorder were significantly associated with current prevalence in uncontrolled analyses, while associations between lack of a confidant as well as religiosity and phobic disorder were not. Female gender (OR = 1·7), perceived low self- confidence (OR = 2·0), and two interaction terms, age × co-morbid psychiatric disorder and race/ethnicity × perceived physical health were associated with phobic disorder in controlled analyses using logistic regression.

Conclusions. We conclude that both social and personal resources, particularly self-confidence, co-morbidity and perceived physical health are important correlates of phobic disorder.

Background. Memory deficits are commonly experienced by patients with schizophrenia, often persist even after effective psychotropic treatment of psychotic symptoms and have been demonstrated to interfere with many aspects of successful psychiatric rehabilitation. Because of significant impact on functional outcome, effective remediation of cognitive deficits has been increasingly cited as an essential component of comprehensive treatment. Efforts to remediate memory deficits have met with circumscribed success, leaving uncertain whether schizophrenia patients can be taught, without experimental induction, independently to employ semantic encoding or a range of other mnemonic techniques.

Method. We examined the feasibility of using memory and problem solving teaching techniques developed within educational psychology – techniques which promote intrinsic motivation and task engagement through contextualization and personalization of learning activities – to remediate memory deficits in a group of in-patients with chronic schizophrenia spectrum disorders.

Results. Although our memory remediation group significantly improved on the memory remediation task, they did not make greater gains on measures of immediate paragraph recall or list learning than the control groups.

Conclusions. Targeted remediation of memory appears to yield task specific improvement but the gains do not generalize to other memory tasks. Subjects receiving memory remediation failed to independently activate mnemonic encoding strategies learned and used successfully within training tasks to other general measures of verbal learning and memory.