Background. Carers' satisfaction with psychiatric services related to information and advice is generally poor. This may be particularly true for services trying to meet the needs of ethnically diverse communities. It is important that services attempt to ameliorate carers' concerns as early as possible. The authors aimed to assess the impact of a brief educational and advice support service on carers of patients with a first episode of psychotic illness.

Method. Carers of all patients identified with a first episode of psychosis in a defined psychiatric catchment area of North London were invited to participate. Following consent from patients and relatives, relatives were randomly allocated to receive (in addition to usual services) a brief intervention comprising education and advice about the disorder from a support team or to usual care from community psychiatric services.

Results. One hundred and six carers were recruited to the study. Take-up of the intervention was less than expected and the intervention had little impact. The authors found no differences over time between the randomized arms for relatives' satisfaction (F=2·3, p=0·14, df=1) or number of days spent by patients in hospital over nine months from entry to the trial (F=1·7, p=0·18, df=1).

Conclusions. It was found that the support and advice intervention for families had little impact on their satisfaction or on patients' outcomes. However, failure to take up the intervention threatens the conclusions as the power to show an effect was reduced. Although family interventions, in general, are considered an important adjunct to the treatment of patients with chronic psychosis, there may be difficulties in providing an educational and support intervention shortly after first onset. How and when psychiatric services provide information and advice to carers of people newly diagnosed with a psychosis requires further study.

Background. In previous studies of subthreshold conditions, co-morbidity has been largely ignored. The purpose was to examine rates of co-morbidity among subthreshold disorders and between subthreshold and full-syndrome disorders for the major non-psychotic classes of disorders from DSM-IV.

Method. Participants came from the Oregon Adolescent Depression Project (mean age=16·6 years; females=52·1%). On the basis of a diagnostic interview (K-SADS), participants were assigned to eight subthreshold disorders (MDD, bipolar, eating, anxiety, alcohol use, substance use, conduct, ADHD).

Results. Of the 1704 adolescents in the analyses, 52·5% had at least one subthreshood disorder. Of those, 40·0% had also experienced a co-morbid subthreshold condition, and 29·9% of those had a second co-morbid subthreshold condition. Of those with a subthreshold, 36·4% also had a full syndrome. The subthreshold forms of externalizing disorders were co-morbid with each other. As expected, subthreshold anxiety was co-morbid with subthreshold MDD but subthreshold anxiety was also co-morbid with subthreshold alcohol, conduct, and ADHD. The pattern of co-morbidities was nearly identical for males and females.

Conclusions. The hypotheses that externalizing disorders would be co-morbid with other externalizing disorders and that internalizing disorders would be co-morbid with other internalizing disorders was partially supported. Co-morbidities between subthreshold disorders and between subthreshold disorders and full syndrome should impact future research and clinical practice. The assessment of subthreshold disorders needs to include the assessment of other subthreshold and full-syndrome conditions.

Background. Elevated rates of psychological morbidity and symptomatology have been widely reported in 1991 Gulf War veterans. The present study used brief self-report instruments to compare the psychological health of Australian Gulf War veterans with that of a randomly sampled military comparison group.

Method. The 12-item Short Form Health Survey (SF-12), 12-item General Health Questionnaire (GHQ-12), Posttraumatic Stress Disorder Checklist – Specific (PCL-S) and Military Service Experience (MSE) questionnaire were administered to 1424 male Australian Gulf War veterans and 1548 male Australian Defence Force members who were operational at the time of the Gulf War conflict, but were not deployed there.

Results. The Gulf War veterans exhibited poorer psychological health, as measured by the above three instruments, than the comparison group members. For Gulf War veterans, the number of stressful experiences, as measured by the MSE questionnaire, was correlated with scores on the three instruments. SF-12 mental health component summary scores and PCL-S caseness, but not GHQ-12 caseness, differed significantly between Gulf War veterans and comparison group members who had been on at least one active deployment.

Conclusions. More than a decade after the 1991 Gulf War, Australian Gulf War veterans are exhibiting higher levels of current (past month) psychological ill-health, as measured using the GHQ-12 and PCL-S, as well as lower mental health status, as measured by the SF-12, than the comparison group. Although not a replacement for formal psychiatric diagnosis, instruments such as those above may aid in the assessment of veterans' psychological health.

Background. Assessment of lifetime major depression is usually made from a single interview. Most previous studies have investigated reliability. Comparison of recall of key symptoms and longitudinal reports shows the accuracy of recall, not just reliability.

Method. At age 25, 1003 members of the Christchurch Health and Development Study cohort were asked to recall key symptoms of depression (sadness, loss of interest) up to age 21. This recall was compared with longitudinal reports at ages 15, 16, 18 and 21 years. Diagnosis was by DSM-III-R and DSM-IV criteria.

Results. Only 4% of those without previous reports recalled key symptoms. Of those with a diagnosis of depression up to age 21, 44% recalled a key symptom. Measures of severity of an episode (number of symptoms, impairment, duration, suicidality) and chronicity (years with a diagnosis, years with suicidal ideation) all strongly predicted recall. Current key symptoms increased recall, even after taking account of severity and chronicity. Being female and receiving treatment also predicted recall, although odds ratios were reduced to 1·6–1·7 when all other predictors were included. Comparison of risk factors for key symptoms showed similar results from longitudinal reports and recall. Sexual abuse, neuroticism, lack of parental attachment, gender, physical abuse and maternal depression were major risk factors in both sets of analyses.

Conclusions. Forgetting of prior episodes of depression was common. Severity, chronicity, current depression, gender and treatment predicted recall. Lifetime prevalence based on recall will be markedly underestimated but the identification of major risk factors may be relatively little impaired.

Background. Chronic fatigue greatly affects quality of life and is a common reason for consulting a physician. Since conventional therapy is often of limited help, fatigued patients may use herbal treatments. This randomized controlled trial evaluated the effectiveness of Siberian ginseng.

Method. Subjects were recruited from advertisements in Iowa (82%) and members of chronic fatigue syndrome support groups (18%). Potential subjects were required to have substantial fatigue [ges ]6 months with no identifiable cause. The mean change in a fatigue measure was compared for placebo and Siberian ginseng at 1 and 2 months. Comparisons were for all subjects and for subjects with characteristics previously identified in the literature as important for categorizing chronic fatigue.

Results. Ninety-six subjects were randomized to treatment groups, and 76 provided information at 2 months of follow-up. Fatigue among subjects assigned to either placebo or Siberian ginseng was substantially reduced during the study, but differences between treatment groups were not statistically significant in the full sample. Fatigue severity and duration had a statistically significant interaction with response to Siberian ginseng at the P<0·05 level. Treatment was effective at 2 months for 45 subjects with less severe fatigue (P=0·04 unadjusted for multiple comparisons) and for 41 subjects with fatigue for [ges ]5 years (P=0·09 unadjusted for multiple comparisons).

Conclusion. Overall efficacy was not demonstrated. However, the findings of possible efficacy for patients with moderate fatigue suggests that further research may be of value.

Background. This study aimed to explore the effects of emotionally salient material on thought disorder in patients with bipolar affective disorder.

Method. Seventy-one participants (20 manic, 15 depressed, 16 currently well patients and 20 non-psychiatric-controls) were interviewed in two conditions: an emotionally salient interview and a non-salient interview. Speech samples were rated using the Scale for the Assessment of Thought, Language and Communication.

Results. Manic patients presented with significantly more thought disorder than any other group in both conditions and exhibited the greatest reaction to emotionally salient material.

Conclusion. The effects of emotional salience on thought, language and communication are not unique to schizophrenic patients. The speech of manic patients is more affectively responsive than the speech of remitted, bipolar depressed and normal participants. The implications of these findings are discussed.

Background. Use of MDMA (ecstasy), a serotonin neurotoxin, has been associated with memory impairment and psychological dysfunction. This study examined cognitive functioning in abstinent MDMA users and MDMA-naïve controls.

Method. Participants completed measures of intelligence, motor function, attention, memory span, verbal fluency, immediate and delayed verbal memory, and working memory. They were also assessed for the presence of psychopathology. In addition to comparing cognitive function in MDMA users relative to controls, the possibility that clinically dysfunctional MDMA use increases the risk of cognitive impairment was examined.

Results. MDMA users exhibited relative deficits in mnemonic and executive functions. Additionally, users that met DSM-IV substance use disorder criteria for lifetime MDMA abuse or dependence exhibited a number of additional deficits relative to those who did not meet these criteria.

Conclusion. These findings suggest that clinically dysfunctional, rather than purely recreational, MDMA use is associated with cognitive impairment. Future research studies of diverse samples of users may shed light on the mechanisms that underlie these differences.

Background. Severe acute respiratory syndrome (SARS) is a novel disease. The authors have limited knowledge of its impact on mental health. The present study aimed to examine the level and extent of psychological distress of SARS survivors following 1-month recovery, to explore patients' negative appraisals of the impact of SARS, and to evaluate the associations between psychological distress and negative appraisals.

Method. The Beck Anxiety Inventory, the Beck Depression Inventory, and a newly developed measure, the SARS Impact Scale (SIS), were mailed to 453 Hong Kong Chinese SARS survivors discharged from hospital for 4 weeks or more.

Results. A total of 425 patients received the questionnaires and 180 (mean age 36·9 years; 120 women) gave valid replies. The response rate was 42·4%. The participants also represented 13·6% of all adult survivors in Hong Kong. About 35% of respondents reported ‘moderate to severe’ or ‘severe’ ranges of anxiety and/or depressive symptoms. It was found that those working as healthcare workers or having family members killed by SARS were more prone to develop subsequent high levels of distress. Factor analyses extracted three meaningful factors of the SIS, namely ‘survival threat’, ‘physical impact’, and ‘social impact’. Negative appraisals at the acute phase and 1-month recovery significantly accounted for substantial portions of variances for anxiety and depressive symptoms, after the effects of other psychosocial variables were controlled.

Conclusions. Psychological distress of SARS survivors at 1-month recovery is real and significant. Negative appraisals may play a pivotal role in the development of psychological distress for SARS survivors, at least in the short term.

Background. The most widely used survey measures in psychiatry, the Composite International Diagnostic Interview (CIDI) and the Clinical Interview Schedule – Revised (CIS-R) have generated estimates of psychiatric morbidity that show considerable variation. Doubts have been raised regarding the validity of these structured lay interviewer assessments. There have been no direct comparisons of the performances of these instruments against a common, established criterion.

Method. A total of 105 unselected primary care attendees were each interviewed with CIDI, CIS-R and SCAN in a single sitting with random order of administration. SCAN was administered by a SCAN trained psychiatrist, and CIDI and CIS-R by a public health doctor. Concordance was estimated for all ICD-10 neurotic disorders. We assessed the overall discriminability of the CIS-R morbidity scale using a receiver operating characteristic (ROC) analysis.

Results. The concordance for CIDI for ICD-10 diagnoses was moderate to excellent (kappa=0·58–0·97). Concordance for CIS-R ranged between poor and moderate (kappa=0·10–0·65). The area under the ROC curve for the CIS-R morbidity scale with respect to any ICD-10 disorder [0·87 (95% CI 0·79–0·95)] indicated good overall discriminability, but poor sensitivity (44%) and high specificity (97%) at the usual CIS-R cut-point of 11/12.

Conclusion. Among primary care attendees the CIDI is a highly valid assessment of common mental disorders, and the CIS-R is moderately valid. Previous studies may have underestimated validity. Against the criteria of all ICD-10 diagnoses (including less severe depressive and anxiety disorders) a much lower CIS-R cut-point is required than that which is usually advocated.

Background. General practitioners (GPs) can be provided with effective training in the skills to manage depression. However, it remains uncertain whether such training achieves health gain for their patients.

Method. The study aimed to measure the health gain from training GPs in skills for the assessment and management of depression. The study design was a cluster randomized controlled trial. GP participants were assessed for recognition of psychological disorders, attitudes to depression, prescribing patterns and experience of psychiatry and communication skills training. They were then randomized to receive training at baseline or the end of the study. Patients selected by GPs were assessed at baseline, 3 and 12 months. The primary outcome was depression status, measured by HAM-D. Secondary outcomes were psychiatric symptoms (GHQ-12) quality of life (SF-36), satisfaction with consultations, and health service use and costs.

Results. Thirty-eight GPs were recruited and 36 (95%) completed the study. They selected 318 patients, of whom 189 (59%) were successfully recruited. At 3 months there were no significant differences between intervention and control patients on HAM-D, GHQ-12 or SF-36. At 12 months there was a positive training effect in two domains of the SF-36, but no differences in HAM-D, GHQ-12 or health care costs. Patients reported trained GPs as somewhat better at listening and understanding but not in the other aspects of satisfaction.

Conclusions. Although training programmes may improve GPs' skills in managing depression, this does not appear to translate into health gain for depressed patients or the health service.

Background. The outbreak of severe acute respiratory syndrome (SARS) posed an unprecedented threat and a great challenge to health professionals in Hong Kong. The study reported here aimed at investigating the origin of stress and psychological morbidity among frontline healthcare workers in response to this catastrophe.

Method. Self-administered questionnaires were sent to frontline healthcare workers in three hospitals. The General Health Questionnaire was used to identify psychological distress. Sociodemographic and stress variables were entered into a logistic regression analysis to find out the variables associated with psychological morbidity.

Results. The response rate was 40%. Sixty-eight per cent of participants reported a high level of stress. About 57% were found to have experienced psychological distress. The healthcare workers' psychological morbidity was best understood by the perceptions of personal vulnerability, stress and support in the workplace.

Conclusion. These findings shed light on the need for hospital administrators to be aware of the extent and sources of stress and psychological distress among frontline healthcare workers during disease outbreak.

Background. Some consider the loss of a child as the most stressful life event. When the death is caused by a malignancy, the parents are commonly exposed not only to their own loss, but also to the protracted physical and emotional suffering of the child. We investigated parental risk of anxiety and depression 4–9 years after the loss of a child owing to a malignancy.

Method. In 2001, we attempted to contact all parents in Sweden who had lost a child due to a malignancy during 1992–1997. We used an anonymous postal questionnaire and utilized a control group of non-bereaved parents with a living child.

Results. Participation among bereaved parents was 449/561 (80%); among non-bereaved 457/659 (69%). We found an increased risk of anxiety (relative risk 1·5, 95% confidence interval 1·1–1·9) and depression (relative risk 1·4, 95% confidence interval 1·1–1·7) among bereaved parents compared with non-bereaved. The risk of anxiety and depression was higher in the period 4–6 years after bereavement than in the 7–9 years period, during which the average excess risks approached zero. Psychological distress was overall higher among bereaved mothers and loss of a child aged 9 years or older implied an increased risk, particularly for fathers.

Conclusions. Psychological morbidity in bereaved parents decreases to levels similar to those among non-bereaved parents 7–9 years after the loss. Bereaved mothers and parents who lose a child 9 years or older have on average an excess risk for long-term psychological distress.

Background. While men with schizophrenia are at higher risk of displaying homicidal behaviours compared with the general population, very little is known about the circumstances related to the triggering of such violent acts among offenders with schizophrenia. The main goal of the present investigation was to describe the surrounding context, psychotic symptoms, target characteristics and other circumstantial factors associated with homicidal acts committed by men with schizophrenia, with or without an additional antisocial personality disorder (APD).

Method. Comprehensive clinical and research interviews, as well as multiple sources of information including reports from social workers and police officers, criminal records, witness statements and questionnaires completed by friends, acquaintances and family members were used to determine specific characteristics surrounding the homicidal acts.

Results. Overall, a significant majority of homicides were considered as the consequence of psychotic symptoms; they mostly involved someone who knew the offender; and they usually occurred in a private residence. However, the subgroup of offenders with both schizophrenia and APD were less likely to be judged as responding to psychotic symptoms; they assaulted a non-relative more frequently, and they were more likely to have used alcohol and to be involved in an altercation with the victim prior to the incident than offenders without APD.

Conclusion. Even for such extreme acts as homicides, the circumstances affecting the occurrence of violence among offenders with schizophrenia may differ when an additional APD diagnosis is present, which would have important implications for prevention and treatment programmes.

Background. The relationship between cognitive function and symptomatology in bipolar disorder is unclear. This study assessed executive function during the manic, depressed and remitted stages of bipolar I disorder.

Method. Tasks assessing phonological and semantic verbal fluency, the Hayling Sentence Completion Test, the Stroop Neuropsychological Screening Test and the Cognitive Estimates Test were administered to manic (n=15), depressed (n=15), and remitted (n=15) bipolar I patients, and to healthy controls (n=30). Multiple regression analyses and analyses of covariance were used to identify potential determinants of executive dysfunction in the three bipolar groups.

Results. Executive function deficits were particularly associated with the manic state. In general, manic patients performed less accurately than the remitted and depressed groups, and their performance deficit was related to the severity of positive thought disorder. The depressed and remitted bipolar groups showed a less widespread pattern of impairment. Deficits in response initiation, strategic thinking and inhibitory control were evident in all the bipolar groups.

Conclusions. Executive function deficits in bipolar I disorder are most evident during mania, and are particularly associated with formal thought disorder. However, deficits in response initiation, strategic thinking and inhibitory control may be more related to the underlying disorder than a particular symptom profile.

Background. Although major depression is a common condition across the age range, there is some evidence from clinical studies that it may be more persistent and disabling in older adults. This study examined the demographic, socio-economic and clinical factors associated with major depression and with persistence of depressive symptoms at 2- and 4-year follow-ups in a large population sample of middle-aged and older adults.

Method. In a sample of 9747 participants aged over 50 in the 1996 wave of the US Health and Retirement Study, the authors assessed the 12-month prevalence of major depression using the Composite International Diagnostic Interview – Short Form (CIDI-SF). Significant depressive symptoms at the time of 1996, 1998 and 2000 interviews were assessed using a short form of the Center for Epidemiological Studies Depression Scale (CES-D).

Results. The 12-month prevalence of CIDI-SF major depression was 6·6%. With age, prevalence declined, but the likelihood of significant depressive symptoms at follow-ups increased. Both prevalence and persistence of significant depressive symptoms at follow-ups were associated with socio-economic disadvantage and physical illness. Persistence of depressive symptoms at follow-ups was also associated with symptoms of anhedonia, feelings of worthlessness, and thoughts of death at baseline.

Conclusions. Sociodemographic, physical health and a specific profile of depressive symptoms are associated with a poorer course of major depression in the middle-aged and older adults. These indicators may identify a subgroup of patients in need of more careful follow-up and intensive treatment.

Background. Neuropsychological impairment is a common finding in schizophrenia. However, a significant proportion of patients are not impaired in conventional neuropsychological tests. In this study, we investigated whether remitted patients with schizophreniform disorder exhibited dysfunctions in specific cognitive tasks.

Method. Twenty remitted, highly functioning patients with schizophreniform disorder and 20 control subjects participated in the study. In addition to background neuropsychological evaluation (WAIS-R IQ, Wisconsin Card Sorting Test (WCST), Trail Making B, Rey–Osterrieth Complex Figure), subjects received a category learning task. The categories consisted of geometric shapes systematically changing in shape and size. Training included the sequential presentation of category members (visual learning) and verbal description of categories.

Results. The patients with schizophreniform disorder had normal IQ, executive functions/psychomotor speed (WCST and Trail Making B) and visual memory (Rey–Osterrieth Complex Figure). In contrast, they displayed impaired categorization performances after visual learning. The performance of the patients improved markedly after verbal description of categories. Verbal knowledge about categories positively correlated with categorization performance in the patients, but not in the controls.

Conclusions. Category learning functions, which include decision-making under uncertainty and feature integration, are impaired in patients with schizophreniform disorder who display normal executive functions and visual memory. These patients may use verbal knowledge as a compensatory strategy in visual tasks.

Background. A lengthy delay often occurs between the onset of symptoms of psychotic disorders and initiation of adequate treatment. In this paper we examine the extent to which this represents a delay in individuals contacting health professionals or a delay in receiving treatment once such contact is made.

Method. Pathways to care were examined in 110 patients of the Prevention and Early Intervention Program for Psychosis in London, Canada. Data were collected using structured interviews with patients, family members, consultation with clinicians and review of case records.

Results. Family physicians and hospital emergency rooms were prominent components of pathways to care. Both delay to contact with a helping professional and delay from such contact to initiation of adequate treatment appear to be about equally important for the sample as a whole, but some individuals appear to be at risk for particularly lengthy delay in the second component. Individuals with younger age of onset, or who had initial contact with professional helpers before the onset of psychosis and were being seen on an ongoing basis at the time of onset of psychosis, had longer delays from first service contact after onset to initiation of adequate treatment. The greater delay to treatment for those being seen at the onset of psychosis does not appear to reflect differences in age, gender, symptoms, drug use or willingness to take medication.

Conclusions. Interventions to reduce treatment delay should increase the public's awareness of the symptoms of psychotic illness and the need to seek treatment, but of equal importance is the education of service providers to recognize such illness and the potential benefits of earlier intervention.

Background. Recent reports have indicated that immigrants have an elevated risk of schizophrenia as well as an increasing tendency for social exclusion. The aim of this study was to compare rates of schizophrenia and other psychoses in immigrants and their children of different ethnic groups with the majority population in Sweden in relation to social adversity.

Method. The study population consists of a national cohort of 1·47 million adults (born 1929–1965) and 1·16 million children and youth (born 1968–1979) in family households from the national census of 1985. Multivariate Cox regression analyses was used to study hospital discharge data during 1991–2000 in relation to socio-economic household indicators from 1985 and 1990 (single adult household, adults having received social welfare, parental unemployment, urban residency, housing and socio-economic status).

Results. First as well as second generation immigrants had higher age and sex adjusted risk ratios for schizophrenia as well as for other psychoses (RRs 1·4–3·1 and 1·0–2·0 respectively) compared with the Swedish majority population. These risk ratios decreased considerably after adjusting for socio-economic indicators, for all groups, but particularly for the non-European immigrants. However, an elevated risk still remained in the Finnish and Eastern and Southern European study groups.

Conclusions. A higher risk of schizophrenia and psychoses was found in two generations of immigrants of diverse ethnicity. The results indicate that social adversity contributes to the higher risk.

Background. Clinical studies suggest that psychotic and paranoid states in late life are associated with cognitive dysfunction. However, it is not clear whether this finding would be observed in general population samples of non-demented elderly, particularly after adjustment for potential confounding factors.

Method. A representative sample of non-demented 85-year-olds living in the community or in institutions in Göteborg, Sweden (N=347) was examined using a psychiatric and physical examination (including a medical history), key-informant interview, psychometric testing and review of medical records. Individuals with psychotic symptoms and paranoid ideation were compared with the mentally healthy regarding tests of verbal ability, inductive logical reasoning, spatial ability, perceptual speed, basic arithmetic, primary memory and secondary memory.

Results. Non-demented 85-year-olds with psychotic symptoms or paranoid ideation performed specifically worse on tests measuring verbal ability, logical reasoning and two tests of spatial ability after adjustment for sex, education, hearing impairment, visual deficits, somatic disorders, depression, 3-year-mortality rate and incident dementia.

Conclusions. Psychotic symptoms and paranoid ideation were associated with lower performance on cognitive tests related to verbal ability, logical reasoning and spatial ability in non-demented 85-year-olds after adjustment for potential confounders.

Background. The descriptive validity of the melancholic features specifier of the DSM-IV major depressive disorder (MDD) is uncertain. Little is known about its relationship to psychiatric co-morbidity, stability across episodes, or strength in predicting course of illness.

Method. The Vantaa Depression Study (VDS) is a prospective, naturalistic cohort study of 269 patients with a new episode of DSM-IV MDD who were interviewed with SCAN and SCID-II between 1 February 1997 and 31 May 1998, and again at 6 and 18 months. Ninety-seven (36%) MDD patients met DSM-IV criteria for the melancholic features specifier, and were contrasted with 172 (64%) subjects with a non-melancholic MDD. The duration of the index episode was examined using a life chart.

Results. We found no difference in rates of any current co-morbid Axis I or II disorders between melancholic and non-melancholic depressed patients. Of those who had melancholic features at the index episode and subsequent episodes during the 18-month follow-up, only 22% (5/23) presented melancholic features during the latter. The non-melancholic subtype switched to melancholic in 25% (8/32) of cases. Differences in the course of melancholic and non-melancholic depression were very minor.

Conclusions. The descriptive validity of the DSM-IV melancholic features specifier may be questionable in MDD. There appear to be no major differences in current co-morbidity, or course of depression between melancholic and non-melancholic patients. The consistency of DSM-IV melancholic features across episodes appears weak.