Background. The heterogeneity of schizophrenic and delusional syndromes by age of onset has frequently been discussed.

Methods. The age distribution of symptoms and 5 year course was studied in a population-based first-episode sample admitted to 10 psychiatric hospitals before the age of 60 (N=232) and in a clinical sample without age limit of consecutive first admissions to a single hospital (N=1109), both samples with broadly diagnosed schizophrenia.

Results. Early-onset patients, particularly men, presented more non-specific symptoms and higher PSE-CATEGO total scores than late-onset patients. In men, symptom severity decreased with increasing age of onset. In women, it remained stable except for an increase of negative symptoms with late-onset. Only a few symptoms changed markedly with age: disorganization decreased, while paranoid and systematic delusions increased steeply across the whole age of onset range. Pronounced age- and sex-differences emerged in illness behaviour, socially negative behaviour and substance abuse. Within the group of late-onset psychoses there were continuous transitions in symptom profiles and no discrimination between schizophrenia and paranoid psychosis or late paraphrenia. The main determinant of social course was onset level of social development. Early-onset patients did not improve in social status, while late-onset patients, prior to retirement, suffered considerable decline in social status.

Conclusions. Gender differences in age at onset and in age trends in symptom severity support the hypothesis of a mild protective effect of oestrogen. Social course results from an interplay between biological factors (age at onset and functional impairment) and development factors (level of social development at onset and illness behaviour).

Background. To assess the prevalence of delusional ideas in primary-care patients.

Method. A survey was carried out with the Aquitaine Sentinel Network of general practitioners (GPs). Consecutive practice attenders were invited to complete the Peters et al. Delusional Inventory (PDI-21) self-report questionnaire, designed to measure delusional ideation in the normal population. GPs, blind to the questionnaire results, provided information on patients' psychiatric history.

Results. Of the 1053 attenders included in the survey, 348 (35%) had a lifetime history of psychiatric disorder, of whom 20 (2%) had a history of broadly defined psychotic disorder. The self-report questionnaire was completed by 790 patients. The range of individual PDI-21 item endorsement in subjects with no psychiatric history varied between 5 and 70%, suggesting that delusional ideation is a dimensional phenomenon lying on a continuum with normality. The main discriminative items between psychotic and non-psychotic patients were those exploring persecutory (OR=15·2, 95% CI 4·3–53·7), mystic (OR=6·4, 95% CI 1·9–22·4) and guilt (OR=5·8, 95% CI 1·5–23·2) ideas.

Conclusions. This survey demonstrates that questions that explore delusions and hallucinations are well-accepted by most primary-care patients. More research is needed on psychotic disorders in primary-care settings to improving early identification of these disorders.

Background. One hundred and thirty-five women with bulimia nervosa participated in a randomized clinical trial designed to determine whether the addition of exposure with response prevention to a core of cognitive-behavioural therapy (CBT) leads to greater clinical improvement and lower risk of relapse. We present results from the end of treatment and 6- and 12-month follow-up.

Methods. Participants received eight sessions of CBT and were then randomized to either exposure to pre-binge cues (B-ERP), exposure to pre-purge cues (P-ERP), or a relaxation training control condition (RELAX).

Results. CBT produced significant clinical change. At the end of the behavioural treatments, there were no significant differences across the three groups on abstinence (66% in B-ERP, 45% in P-ERP and 47% in RELAX), or frequency of bingeing and purging. B-ERP, but not P-ERP, significantly reduced anxiety on the cue reactivity assessment, food restriction, body dissatisfaction and depression. These differences were not maintained at 6-month follow-up. At 12-months, B-ERP was independently associated with lower food restriction and better global functioning.

Conclusions. CBT is a highly effective treatment for bulimia nervosa. B-ERP was modestly superior to P-ERP at post-treatment; however, the advantage did not remain throughout the follow-up interval. ERP for bulimia nervosa is an expensive and logistically complicated treatment that does not appear to offer any significant additive benefits that are proportional to the amount of effort required to implement the treatment.

Background. So-called atypical depressive symptoms (carbohydrate craving, prolonged sleep, weight gain, increased appetite) frequently emerge in association with low illumination to which people are ordinarily exposed indoors, or even outdoors at extreme latitudes in wintertime. Our objective was to analyse the effect of physical exercise alone or combined with bright light on mood and the health-related quality of life during winter.

Methods. We carried out a randomized controlled trial on 120 indoor employees in southern Finland between November and January. The subjects were allocated to supervised fitness training under bright (2500–4000 lx) or ordinary (400–600 lx) light conditions in a gym 2–3 times weekly for 8 weeks, or supervised relaxation training once a week over the same period as active placebo. We collected questionnaire data on the changes in mood and health-related quality of life after 4 and 8 weeks of training, and after 4 months follow-up.

Results. Fitness training in bright light resulted in greater relief from atypical depressive symptoms and more vitality than in ordinary room light. Compared with relaxation alone, the former regime improved general mental health and social functioning in addition to the improvement in depressive symptoms and vitality, whereas the latter only increased vitality.

Conclusions. Supervised physical exercise combined with exposure to bright light appears to be an effective intervention for improving mood and certain aspects of the health-related quality of life in wintertime. This effect appears unrelated to the history of season-dependent symptoms, being noticeable among healthy individuals.

Background. Few studies have examined prospectively both the direct and buffering effects of types of social support and social networks on mental health. This paper reports longitudinal associations between types of social support and psychiatric morbidity from the Whitehall II study.

Methods. Social support was measured by the Close Persons Questionnaire and psychiatric morbidity by the General Health Questionnaire at baseline (1985–1988) and at first follow-up (1989) in 7697 male and female London-based civil servants aged 35–55 years at baseline. The cohort was followed up and baseline measures were used to predict psychiatric disorder measured by the General Health Questionnaire at second follow-up (1991–1993).

Results. Longitudinal analyses showed that low confiding/emotional support in men and high negative aspects of close relationships in men and women were associated with greater risk of psychiatric morbidity even after adjustment for baseline General Health Questionnaire score. There was no evidence of a buffering effect among men or women who experienced life events or chronic stressors. Controlling for a personality measure of hostility did not affect the observed relations.

Conclusions. The present findings illustrate that different types of support are risk factors for psychological distress and that they operate in different ways for men and women. Direct effects of emotional support are predictive of good mental health in men and negative aspects of close relations predict poor mental health in both men and women. Emotional support is predictive of good mental health in women whereas, confiding alone is not.

Background. A significant number of patients with severe psychiatric disorders remain untreated in the community although health services are available. The factors related to non-treatment are not well understood.

Method. A door-to-door survey was conducted on an Indian urban population of 100 000 using standardized screening and clinical instruments as a part of a larger epidemiological study. Treatment status was determined from multiple sources of information.

Results. Nearly one-third of 261 schizophrenia patients were found never to have received treatment. They were older in age and ill for a longer duration than those who had been treated and were more symptomatic and severely disabled. They were more often uneducated and divorced and lived with larger extended/joint families. This last factor was considered as being the important factor in determining whether the patient received treatment.

Conclusion. The larger extended/joint family, which was able to compensate and cope with the dysfunctional member, seemed to be the crucial factor related to non-treatment of the schizophrenic patient.

Background. Twin studies have long been used to disentangle the role of genetic and environmental factors in the aetiology of psychiatric disorders. However, the validity of the twin method depends on the equal environment assumption – that monozygotic (MZ) and dizygotic (DZ) twins are equally correlated in their exposure to environmental factors of aetiological importance for the disorder under study.

Methods. Both members of 822 female–female twin pairs from a population-based registry previously assessed for a range of psychiatric and substance use disorders were asked 12 questions assessing the similarity of their environmental experiences in childhood and adolescence. We examined whether the similarity of environmental experiences predicted concordance for psychiatric and substance abuse disorders by both a ‘pair-wise’ and ‘individual’ method utilizing logistic regression. We also examined smoking initiation, where prior evidence suggested a role for adolescent social environment.

Results. Three factors were derived from these items: ‘Childhood treatment’, ‘Co-socialization’ and ‘Similitude’. Members of twin pairs agreed substantially in their recollections of these experiences. Compared with DZ twins, MZ twins reported comparable resemblance in their childhood treatment, but socialized together more frequently and reported that parents, teachers and friends more commonly emphasized their similarities. None of these three factors significantly predicted twin resemblance for major depression, generalized anxiety disorder, panic disorder, phobias, nicotine dependence or alcohol dependence. However, co-socialization significantly predicted twin resemblance for smoking initiation and perhaps for bulimia.

Conclusion. Differential environmental experiences of MZ and DZ twins in childhood and adolescence are unlikely to represent a substantial bias in twin studies of most major psychiatric and substance dependence disorders but may influence twin similarity for the initiation of substance use.

Background. Cross-sectional studies of non-cognitive symptoms in dementia show that patients with psychotic symptoms tend to have more disturbed behaviour. However, it is not known whether individuals who experience psychiatric symptoms early in dementia are more prone to develop behavioural problems later in the illness.

Method. The behaviour of 86 community-dwelling subjects with dementia was intensively studied for 4 years or until death, using an informant interview which was administered every 4 months on a median of eight occasions. The extent to which psychiatric symptoms, age, sex and cognitive function predicted clinically significant physical aggression or motor hyperactivity was assessed.

Results. Physical aggression was predicted by sad appearance and motor hyperactivity was predicted by persecutory ideas. These associations were robust, remaining significant over 2, 3 and 4 years of follow-up and were independent of cognitive function, age, sex and duration of illness.

Conclusions. There may be two distinct longitudinal syndromes of non-cognitive symptoms in dementia. This suggests that important aberrant behaviours in late dementia may share pathophysiological mechanisms with psychiatric symptoms in early dementia.

Background. Primary care attenders with a common mental disorder (CMD) frequently present with somatic symptoms. This study aimed to examine somatic and psychological models of CMD in primary care attenders in India.

Methods. Cross-sectional survey of attenders at two primary care clinics. Psychiatric caseness was determined on three criteria: standardized psychiatric interview (biomedical criterion), patients' self-assessment of emotional disorder (emic criterion) and health care provider diagnosis. The GHQ-12 and the PPQ, which emphasize psychological and somatic symptoms respectively, were used as screening instruments.

Results. Although somatic symptoms were the presenting complaints for 97% of subjects, 51% of subjects with a biomedically defined CMD had a psychological illness attribution. Patients with psychological attributions were more likely to be women, to have a longer duration of illness, to have higher CISR scores and were more likely to be recognized by the primary health care (PHC) physician. The GHQ-12 was superior to the PPQ in identifying cases of CMD against the biomedical criterion for both psychologizers and somatizers; both instruments performed equally well against the emic and care provider criteria.

Conclusions. Psychological models may be acquired by patients as CMD becomes more chronic or severe, making them more likely to be detected by PHC physicians. Psychological symptoms are superior to somatic symptoms in detecting CMD. Shorter versions of the GHQ have comparable discriminating abilities to the 12-item version and offer the practical advantage of brevity, which may make them more acceptable to PHC physicians as a clinical screening tool.

Background. The equivalency of the Composite International Diagnostic Interview delivered by human interviewers (CIDI) and its computerized version (CIDI-Auto) was examined for anxiety and depressive disorders.

Methods. Subjects were 40 patients at an Anxiety Disorders Clinic and 40 general medical practice attenders. The CIDI-Auto and CIDI were administered in counterbalanced order on the same day and measures of computer attitudes and the acceptability of the two interview formats were also taken.

Results. The CIDI-Auto and the CIDI were found to be equally acceptable to subjects on the dimensions of comfort and preference, while the CIDI-Auto was rated as less embarrassing but too long in comparison with the CIDI. The agreement between the two formats was acceptable with kappa values for ICD-10 diagnoses being above 0·65 and for DSM-III-R diagnoses above 0·5 except for two diagnoses (generalized anxiety disorder and dysthymia). Discrepancies between the two formats were predicted by computer attitudes and not by computer experiences or the tendency to respond in a socially desirable fashion.

Conclusions. It is concluded that the CIDI-Auto in its self-administered form is an acceptable substitute for the CIDI for suitable subjects.

Background. Studies from several countries have shown a decline, in the last few decades, of the number of admissions with a diagnosis of schizophrenia. This could be due to a fall in the incidence of schizophrenia, but it also could be due to confounding factors. The hypothesis tested in the study is that the incidence of schizophrenia is actually falling because of a decrease in the presence of a seasonal aetiological agent.

Methods. The hypothesis was tested by analysing the dates of birth of the patients discharged with a diagnosis of schizophrenia from NHS hospitals in England and Wales and would be confirmed by an appropriate change in the seasonality of the births over time.

Results. Evidence of seasonality has been observed in the schizophrenic births, but with no significant change over time.

Conclusions. The fall in first admissions with a diagnosis of schizophrenia does not seem to be due to a change in the prevalence of a seasonal aetiological factor. Therefore, either there has been a reduction in incidence due to a change in a non-seasonal agent, or the incidence of schizophrenia is not changing and the fall in first admissions is due to confounding factors.

Background. While neuropathological studies indicate a high risk for Alzheimer's disease in adults with Down's syndrome, neuropsychological studies suggest a lower prevalence of dementia. In this study, cognitive deterioration in adults with Down's syndrome was examined prospectively over 4 years to establish rates and profiles of cognitive deterioration.

Methods. Fifty-seven people with Down's syndrome aged 30 years or older were assessed using a battery of neuropsychological tests on five occasions across 50 months. Assessments of domains of cognitive function known to change with the onset of Alzheimer related dementia were employed. These included tests of learning, memory, orientation, agnosia, apraxia and aphasia. The individual growth trajectory methodology was used to analyse change over time.

Results. Severe cognitive deterioration, such as acquired, apraxia and agnosia, was evident in 28·3% of those aged over 30 and a higher prevalence of these impairments was associated with older age. The rate of cognitive deterioration also increased with age and degree of pre-existing cognitive impairment. Additionally, deterioration in memory, learning and orientation preceded the acquisition of aphasia, agnosia and apraxia.

Conclusions. The prevalence of cognitive impairments consistent with the presence of Alzheimer's disease is lower than that suggested by neuropathological studies. The pattern of the acquisition of cognitive impairments in adults with Down's syndrome is similar to that seen in individuals with Alzheimer's disease who do not have Down's syndrome.

Background. According to the psychosocial vulnerability model, the health of hostile individuals is at greater risk than that of non-hostile individuals, due partly to lesser ability of the former to cope with psychosocial stress situations. We examined whether hostile individuals were more vulnerable than others to health problems when faced with stressful changes in their working lives.

Methods. Hostility, sickness absence and psychosocial stressors in 866 local government employees over a 5-year period, which included severe economic decline, were investigated. Hostility was measured by a questionnaire. Data on medically certified sickness absence were obtained from the records of the local authority. Information about exposure to psychosocial stressors after assessment of hostility was also derived from these records, and from reports from the subjects.

Results. Exposure to stressors during the period of economic decline was related to increased rates of sickness absence. In men, hostility increased risk of sickness absence after exposure to stressors only in cases of absence because of trauma. In women, hostility increased risk of absence through sickness overall and absence because of musculoskeletal disorders in individuals facing stressors such as severe organizational downsizing, high or increased levels of job demands or negative change in work. Findings were adjusted for sickness absence at the beginning of the decline, socio-economic background and behavioural risk factors.

Conclusions. The psychosocial vulnerability model was partly supported. However, heightened vulnerability through hostility may differ between the sexes, since it was more evident in the women studied than in the men.

Background. We report the prevalence, clinical characteristics, frequency of mental health treatment, demographic correlates, frequency of co-morbid psychiatric conditions, and general health ramifications of DSM-IV blood-injection-injury phobia in the general population.

Method. The Diagnostic Interview Schedule (version III-R), which included questions on blood-injection-injury phobia, was administered to 1920 subjects in the Baltimore ECA Follow-up Study.

Results. The estimated unweighted lifetime prevalence of blood-injection-injury phobia was 3·5%. The median age of onset was 5·5 years; 78% had had symptoms within the last 6 months. Subjects with blood-injection-injury phobia (cases) had higher lifetime histories of fainting and seizures than those without (non-cases). None reported seeking mental health treatment specifically for phobia. Prevalences were lower in the elderly and higher in females and persons with less education. Cases had significantly higher than expected lifetime prevalences of other psychiatric conditions, including marijuana abuse/dependence, major depression, obsessive–compulsive disorder, panic disorder, agoraphobia, social phobia and other simple phobia. Cases and non-cases did not differ with regard to usual health-care settings, regular care for specific medical conditions, numbers of out-patient visits or hospitalizations, or previous general anaesthesia or live births. However, diabetics with blood-injection-injury phobia had higher than expected rates of macrovascular complications.

Conclusion. Blood-injection-injury phobia is common, especially in females and those with less education, and it is associated with several co-morbid psychiatric conditions. No strong, broad general health ramifications of this phobia are apparent. However, diabetics with this phobia appear at particular risk for complications; this deserves further study.

Background. Factor analysis has been employed to identify latent variables that are unifying constructs and that parsimoniously describe correlations among a related group of variables. Confirmatory factor analysis is used to test hypothesized factor structures for a set of variables; it can also, as in this paper be used to model data from two or more groups simultaneously to determine whether they have the same factor structure.

Method. Non-psychotic psychiatric morbidity, elicited by the Revised Clinical Interview Schedule (CIS-R), from four culturally diverse populations was compared. Confirmatory factor analysis was employed to compare the factor structures of CIS-R data sets from Santiago, Harare, Rotherhithe and Ealing. These structures were compared with hypothetical one and two factor (depression–anxiety) models.

Results. The models fitted well with the different data sets. The depression–anxiety model was marginally superior to the one factor model as judged by various statistical measures of fit. The two factors in depression–anxiety model were, however, highly correlated.

Conclusions. The findings suggest that symptoms of emotional distress seem to have the same factor structure across cultures.

Background. Previous research has shown an increased risk of mortality after spousal bereavement, with the highest risk in the first weeks or months closest to the loss. One difficult issue in these designs is appropriate covariates and control groups.

Method. This study is based on 1993 pairs of twins discordant for marital status and on 35860 married individuals from the Swedish Twin Registry born between 1886 and 1958 and followed for marital and vital status between 1981 and 1993.

Results. Spousal bereavement was a risk factor for mortality for both men and women using the still married co-twin as a control to the widowed proband, and controlling for earlier health status and health-related risk factors. The mortality risk was higher for young-old (under 70 years) individuals, and for recently widowed than for longer-term widowed. Young-old women had a pattern with increased mortality risk during the first years after bereavement, but also a markedly decreased risk if they survived 4 years after bereavement, as compared to married women.

Conclusions. The results support a causal effect of bereavement on mortality. The decrease in risk for long-term young-old women is congruent with reports by widows of psychological growth after bereavement, involving increased sense of mastery and competence after learning to live in new sets of circumstances following the loss of their husband.

Background. There has been an increase in the numbers of homeless young people in Britain. Little is known of the health and social welfare needs of this population.

Method. This case–control study compares a random sample of homeless people aged under 22 years recruited from consecutive attenders at two of London's largest facilities for homeless young people with a contemporaneous sample of domiciled young people recruited through general practice registration lists. The homeless and domiciled groups were compared on measures of childhood care, education and psychiatric disorder.

Results. One hundred and sixty-one homeless people (88% of those approached) and 107 domiciled subjects (60% of those approached) were interviewed. Sixty-nine per cent of homeless and a third of the domiciled subjects reported a childhood lacking in affection, with indifferent and often violent carers. Psychiatric disorder was identified in 62% of homeless respondents and a quarter of the domiciled population. A fifth of homeless and 5 domiciled respondents had attempted suicide in the previous year. Multivariate analysis suggest that childhood adversity, low educational attainment and the prior presence of psychiatric disorder all independently increase the likelihood of homelessness in a youthful population.

Conclusions. The evidence presented in this paper supports the hypotheses that characterize the young homeless population as experiencing higher rates of childhood adversity and psychiatric disorder than their domiciled contemporaries. A tentative model is suggested whereby childhood experiences, educational attainment and the prior presence of psychiatric disorder all independently increase the likelihood of homelessness in a youthful population.

Background. Within the framework of developmental psychopathology the outcome of male former child and adolescent psychiatric patients at age 36 or 38 was studied in order to add to the limited knowledge in this field.

Methods. A total of 269 former child psychiatric patients of male sex and a control group of more than 2700 men, who were all born in 1952, were compared with regard to mortality, delinquency and adult psychiatric disorders. The study was based on case-file data from assessments conducted with the child and adolescent psychiatric patients and on adults, derived from either federal registers (mortality, delinquency) or army health records and records of the psychiatric facilities of the canton. The study is based on lifetime prevalence rates.

Results. The two samples did not differ with regard to mortality rates. Delinquency tended to be more prevalent and psychiatric disorders were significantly more prevalent among the former child psychiatric patients. Close to 10% of the latter group showed major delinquency, one-quarter was psychiatrically disturbed and 30% displayed one of these two indicators or maladjustment at least once during the follow-up period. A correspondence in pattern of varying between child and adult psychiatric spectrum disorders was observed. Whereas the type of child and adolescent psychiatric disorders did not predict adult maladjustment, there was some indication that deprived environments, broken homes and parental psychiatric disorders during childhood increased the likelihood of poor adult outcome.

Conclusions. This study clearly underlines the long-term negative effects of child and adolescent mental abnormalities in males.

Background. Previous studies on assortment for psychiatric disorders have reported discrepant findings. We aimed to test whether there is a significant association for psychiatric diagnoses, including alcoholism, generalized anxiety disorder, major depressive disorder, panic disorder and phobias between husbands and wives in two population-based samples. We further evaluated whether marital resemblance occurs primarily within or across psychiatric disorders and if assortment for psychopathology is primary or secondary to assortment for correlated variables.

Methods. A model for mate selection addressed whether the correlation between mates for psychiatric disorders arises from direct assortment (primary homogamy) or through correlation with other variables for which assortment occurs (secondary homogamy) or through cross-variable assortment. The model accounted for within-person co-morbidity as well as across-spouse data.

Results. Findings suggested that a moderate degree of assortment exists both within and across psychiatric diagnoses. Only a small amount of the observed marital resemblance for mental illness could be explained by assortment for correlated variables such as age, religious attendance and education. Similar results were obtained for the two samples separately and confirmed in their joint analysis, revealing that the co-morbidity and assortment findings, except for the marital correlation for age, religious attendance and education, replicate across samples.

Conclusions. Significant but moderate primary assortment exists for psychiatric disorders. The bias in twin studies that have ignored the small amount of assortment is negligible.

Background. This paper reports on a two-stage community-based epidemiological study of selected minor psychiatric disorders conducted on an adult African population in South Africa.

Methods. Using a modified random cluster sampling method, 354 adults were identified as the first-stage sample, with the SRQ-20 being used as a first-stage screen. Clinical interviews based on DSM-IV checklists for generalized anxiety disorder, major depression and dysthymia were administered as the second-stage criterion to 81 subjects from the sample.

Results. The weighted prevalence for generalised anxiety and depressive disorders was 23·9% (95% CI 15·1%–32·7%), comprising: generalized anxiety 3·7%, major depression 4·8%, dysthymia 7·3%, and major depression and dysthymia 8·2%. Statistically significant associations were found between caseness and age, marital status, employment, income and educational level.

Conclusions. The results are discussed in relation to comparative local and international data as well as in the context of the current restructuring of the mental-health care system in South Africa from tertiary curative care to integrated primary mental-health care.