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

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

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

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

Background. In order to improve the treatment of medication-resistant negative symptoms in schizophrenia, new interventions are needed. Neuropsychological considerations and older reports in the literature point towards a potential benefit of body-oriented psychological therapy (BPT). This is the first randomized controlled trial specifically designed to test the effectiveness of manualized BPT on negative symptoms in chronic schizophrenia.

Method. Out-patients with DSM-IV continuous schizophrenia were randomly allocated to either BPT (n=24) or supportive counseling (SC, n=21). Both therapies were administered in small groups in addition to treatment as usual (20 sessions over 10 weeks). Changes in negative symptom scores on the Positive and Negative Symptom Scale (PANSS) between baseline, post-treatment and 4-month follow-up were taken as primary outcome criteria in an intention-to-treat analysis.

Results. Patients receiving BPT attended more sessions and had significantly lower negative symptom scores after treatment (PANSS negative, blunted affect, motor retardation). The differences held true at 4-month follow-up. Other aspects of psychopathology and subjective quality of life did not change significantly in either group. Treatment satisfaction and ratings of the therapeutic relationship were similar in both groups.

Conclusions. BPT may be an effective treatment for negative symptoms in patients with chronic schizophrenia. The findings should merit further trials with larger sample sizes and detailed studies to explore the therapeutic mechanisms involved.

Background. There is a common assumption that Black patients with a psychotic mental illness experience longer treatment delays during a first episode. We sought to investigate this issue in a large cohort of patients with a first episode of psychosis.

Method. All patients with a first episode of psychosis presenting to secondary mental health services within tightly defined catchment areas in south-east London and Nottingham over a 2-year period were included in the study. Data relating to duration of untreated psychosis (DUP) and clinical and sociodemographic characteristics were collected from patients, relatives and case-notes.

Results. There was no evidence that African-Caribbean or Black African patients experienced longer periods of untreated psychosis than White British patients prior to first contact with services. There was evidence that Black African patients experienced shorter periods of untreated psychosis than White British patients.

Conclusions. Contrary to what is commonly assumed, our study suggests that Black patients with a psychotic mental illness do not experience longer treatment delays prior to first contact with services than White British patients. This suggests that strategies to reduce treatment delays targeted specifically at Black patients will be of limited value.

Background. Very few large national epidemiologic surveys have examined the prevalence of psychiatric disorders among Asians and Native Americans due to small sample sizes. Very little is also known about the co-occurrences between substance use disorders and mood and anxiety disorders among these two minority groups and how their rates compare to Whites, Blacks, and Hispanics.

Method. Analyses were based on a large (n=43093) nationally representative survey of the adult (18+ years), U.S. population supplemented by a group quarters sampling frame. Prevalences and associations of major DSM-IV mood, anxiety and substance use disorders were examined among all major race/ethnic subgroups of the population.

Results. Twelve-month rates of most mood, anxiety and substance use disorders were generally greatest among Native Americans and lowest among Asians. For most race/ethnic subgroups, alcohol and drug dependence, but not abuse, were significantly associated with mood disorders. With few exceptions, there were no significant associations between alcohol and drug abuse and anxiety disorders. In contrast, alcohol dependence was associated with most anxiety disorders among Whites, Blacks and Asians, but not among Native Americans.

Conclusions. The 12-month prevalence of substance use, mood, and anxiety disorders varied greatly across the five major race/ethnic subgroups of the population. Twelve-month co-occurrence of substance use disorders and mood and anxiety disorders was pervasive among all race/ethnic subgroups. Future research is also needed to understand race/ethnic differentials in prevalence and co-occurrence of these disorders with a particular focus on factors that may give rise to them.

Background. While pre-trauma personality and mental health measures are risk factors for post-traumatic stress disorder (PTSD), such information is usually obtained following the trauma and can be influenced by post-trauma distress. We used data collected from a community-based survey of young adults before and after a major natural disaster to examine the extent to which participants' traumatic experiences, demographic and pre-trauma risk factors were associated with their screening positive for PTSD when re-interviewed.

Method. A representative selection of 2085 young adults from the Australian Capital Territory and environs, interviewed in 1999 as part of a longitudinal community-based survey, were re-interviewed 3–18 months after a major bushfire had occurred in the region. When re-interviewed, they were asked about their experiences of trauma threat, uncontrollable and controllable traumatic experiences and their reaction to the fire. They were also screened for symptoms of fire-related PTSD experienced in the week prior to interview.

Results. Four-fifths of participants were exposed to the trauma with around 50% reporting having experienced uncontrollable traumatic events. Reporting PTSD symptoms was associated with being female, having less education, poorer mental health and higher levels of neuroticism prior to the trauma. Particular fire experiences, including being evacuated and feeling very distressed during the disaster, were more strongly associated with PTSD symptoms compared with pre-trauma measures.

Conclusions. While demographic and pre-trauma mental health increased the likelihood of reporting PTSD symptoms, exposure to trauma threat and reaction to the trauma made greater contributions in explaining such symptoms as a result of this disaster.

Background. Although alcohol dependence (AD) and major depression (MD) are highly co-morbid, their causal relationship is unclear. In this longitudinal study, we used a genetically informative population-based twin sample to examine the age-at-onset distributions and the temporal relationship of AD and MD.

Method. Our sample included 7477 twins, whose diagnoses of AD and MD and age-at-onset information were obtained from structured interviews. Individual-level survival analyses were conducted based on 2603 monozygotic (MZ) twins, and co-twin diagnosis was included in models as an index of familiar liability to AD and MD.

Results. The age-at-onset distributions of AD and MD differed substantially. Most onsets of AD were in young adulthood, whereas MD had a flatter distribution across age. Most subjects, especially women, had an onset of MD preceding AD. Prior MD significantly affected risk for developing AD, and this risk decreased over time. By contrast, preceding AD had negligible effects on the risk for future MD. Familial risk was transmitted within disorders but there was little evidence of additional familial liability shared across disorders.

Conclusions. Risk for developing AD was substantially increased by a prior episode of MD. The association was only partially accounted for by familial factors, providing support for a direct causal effect such as self-medication. The etiologic path from AD to MD was insignificant.

Background. Patterns of co-occurrence among the common mental disorders may provide information about underlying dimensions of psychopathology. The aim of the current study was to determine which of four models best fits the pattern of co-occurrence between 10 common DSM-IV and 11 common ICD-10 mental disorders.

Method. Data were from the Australian National Survey of Mental Health and Well-Being (NSMHWB), a large-scale community epidemiological survey of mental disorders. Participants consisted of a random population-based sample of 10641 community volunteers, representing a response rate of 78%. DSM-IV and ICD-10 mental disorder diagnoses were obtained using the Composite International Diagnostic Interview (CIDI), version 2.0. Confirmatory factor analysis (CFA) was used to assess the relative fit of competing models.

Results. A hierarchical three-factor variation of a two-factor model demonstrated the best fit to the correlations among the mental disorders. This model included a distress factor with high loadings on major depression, dysthymia, generalized anxiety disorder (GAD), post-traumatic stress disorder (PTSD) and neurasthenia (ICD-10 only); a fear factor with high loadings on social phobia, panic disorder, agoraphobia and obsessive–compulsive disorder (OCD); and an externalizing factor with high loadings on alcohol and drug dependence. The distress and fear factors were best conceptualized as subfactors of a higher order internalizing factor.

Conclusions. A greater focus on underlying dimensions of distress, fear and externalization is warranted.

Background. There is evidence that cannabis use might be relevant to the aetiology of schizophrenia. We aimed to measure any change in cannabis use over time in those first presenting with schizophrenia in South-East London from 1965 to 1999, and compare this with change in use in those presenting with non-psychotic psychiatric disorders.

Method. The rate of cannabis use in the year prior to first ever presentation was measured over seven time periods. Logistic regression modelling was used to determine (a) whether cannabis use changed over time, after controlling for age, sex and ethnicity, and (b) whether there was an interaction between diagnosis and time.

Results. Cannabis use increased over time in both the schizophrenia group [odds ratio per time period (OR) 2·03, 95% confidence interval (CI) 1·74–2·38, p<0·0001] and the non-psychotic disorders group (OR 1·24, 95% CI 1·05–1·47, p=0·012), after controlling for age, sex and ethnicity. However, the effect of time was significantly greater in the schizophrenia group than in the non-schizophrenia group (χ2=17, p<0·0001).

Conclusion. Cannabis use in the year prior to presentation with schizophrenia increased markedly between 1965 and 1999, and disproportionately so compared to increase in cannabis use in other psychiatric disorders.

Background. This study questions the 6-month duration criterion for generalized anxiety disorder (GAD) used in DSM-III-R and DSM-IV.

Method. In adults from age 20/21 to 40/41 in the prospective Zurich Cohort Study, four groups of generalized anxiety syndromes defined by varying duration (2 weeks, 1 month, 3 months and 6 months) were compared.

Results. Applying DSM-III (1979–1999) and DSM-III-R (1986–1999) criteria, there were no significant differences between the four groups in terms of family history of anxiety, work impairment, distress, treatment rates or co-morbidity with major depressive episodes (MDEs), bipolar disorder or suicide attempts. Only social impairment related to the length of episodes. The 6-month criterion of DSM-III-R and DSM-IV GAD would preclude this diagnosis in about half of the subjects treated for generalized anxiety syndromes.

Conclusions. In this epidemiological sample, the 6-month duration criterion for GAD could not be confirmed as clinically meaningful. GAD syndromes of varying duration form a continuum with comparable clinical relevance.

Background. In view of the potential utility of personality-based groupings in eating disorders (EDs), and the lack of studies using this approach in large samples of individuals with anorexia nervosa (AN), this study set out to examine (i) the nature of personality-based clusters of women with lifetime AN and (ii) if these clusters are associated with either clinical symptoms or aetiological variables.

Method. The self-report Dimensional Assessment of Personality Pathology (DAPP) was completed by 153 women with a lifetime diagnosis of DSM-IV AN. A cluster analysis was used to identify personality-based subgroups. Clusters were then compared on clinical and aetiological variables.

Results. Three personality-based clusters were identified, defined by broad, avoidant and compulsive types of personality pathology. Dimensions of low dissocial behaviour, high inhibition and high compulsivity were common to all clusters, while dimensions related to emotional dysregulation appeared more heterogeneous. Clinical symptoms were not related to personality profile with the exception of a trend towards more fasting behaviour in the broad group. The compulsive cluster with the narrowest range of extreme personality traits reported the highest familial risk of eating pathology.

Conclusions. The three clusters identified in our AN sample were similar to those previously identified in broader eating disordered samples. Personality-based clusters did not correspond overall to clinical symptoms but aetiological differences supported their validity. Broader personality pathology indicative of emotional dysregulation, problems with identity and relationships, in addition to core traits, may increase vulnerability to AN in those with less familial risk.

Background. The use of strategies to aid performance when undertaking neuropsychological tasks is dependent on intact fronto-striatal circuitry, and growing evidence suggests impaired spontaneous use of strategies in patients with obsessive–compulsive disorder (OCD). However, studies to date have not examined the effects of strategy training on task performance in OCD or in trichotillomania (compulsive hair-pulling, a condition that has been argued to share overlap with OCD in terms of phenomenology and co-morbidity).

Method. The ability to generate novel visuospatial sequences using a computer interface was examined before and after undertaking optimal strategy training in 20 OCD patients, 17 trichotillomania patients, and 20 controls (matched for age, education, and IQ).

Results. OCD patients failed to improve ability to generate novel sequences above baseline despite successfully completing strategy training to the same extent as other groups. In contrast, performance of trichotillomania patients improved significantly after training to the same extent as controls. Groups did not differ on memory span, trial-by-trial action monitoring, or ability to generate novel visuospatial sequences prior to strategy training.

Conclusions. Strategy implementation deficits, suggestive of cognitive inflexibility and fronto-striatal dysfunction, appear integral to the neurocognitive profile of OCD but not trichotillomania. Future research should investigate cognitive flexibility in obsessive–compulsive spectrum disorders using a variety of paradigms, and clarify the contribution of specific neural structures and transmitter systems to deficits reported.

Background. Clinical judgments about the likelihood of suicide attempt would be aided by an index of risk factors that could be quickly assessed in diverse settings. We sought to develop such a risk index for 12-month suicide attempts among suicide ideators.

Method. The National Comorbidity Survey Replication (NCS-R), a household survey of adults aged 18+, assessed the 12-month occurrence of suicide ideation, plans and attempts in a subsample of 5692 respondents. Retrospectively assessed correlates include history of prior suicidality, sociodemographics, parental psychopathology and 12-month DSM-IV disorders.

Results. Twelve-month prevalence estimates of suicide ideation, plans and attempts are 2·6, 0·7 and 0·4% respectively. Although ideators with a plan are more likely to make an attempt (31·9%) than those without a plan (9·6%), 43% of attempts were described as unplanned. History of prior attempts is the strongest correlate of 12-month attempts. Other significant correlates include shorter duration of ideation, presence of a suicide plan, and several sociodemographic and parental psychopathology variables. Twelve-month disorders are not powerful correlates. A four-category summary index of correlates is strongly related to attempts among ideators [area under the receiver operator characteristic curve (AUC)=0·88]. The distribution (conditional probability of attempt) of the risk index is: 19·0% very low (0·0%), 51·1% low (3·5%), 16·2% intermediate (21·3%), and 13·7% high (78·1%). Two-thirds (67·1%) of attempts were made by ideators in the high-risk category.

Conclusions. A short, preliminary risk index based on retrospectively reported responses to fully structured questions is strongly correlated with 12-month suicide attempts among ideators, with a high concentration of attempts among high-risk ideators.

Background. Most mental health research tools are developed in Western, urban contexts. Few studies have evaluated the applicability of these research tools in rural populations of non-Western countries. We examined the cultural acceptance and psychometric performance of the 12-item General Health Questionnaire (GHQ) in China's rural villages.

Method. Ethnographic investigations were conducted to assess the cultural applicability of self-report rating scales among villagers. This was followed by a survey of 1401 rural residents, randomly selected from 48 villages of Shandong province using stratified multistage cluster sampling. The respondents were administered the GHQ and the Composite International Diagnostic Interview (CIDI).

Results. The GHQ, when administered by trained interviewers, was culturally acceptable to rural residents. The scale had good psychometric properties in the study population. The area under the curve was 0·86. At a cut-off of 1/2, the sensitivity and specificity were 80·6% and 79·3% respectively.

Conclusions. The ethno-psychometric evaluation showed that the GHQ was both culturally valid and psychometrically sound in the Chinese rural context.

Background. The Psychiatric Diagnostic Screening Questionnaire (PDSQ) is a reliable and valid self-report scale designed to screen for the most common DSM-IV Axis I disorders encountered in out-patient mental health settings. The present report is the second large-scale validation study of the PDSQ in psychiatric out-patients. Because some of the sizes of the diagnostic groups in the initial report were modest, it is important to determine whether the recommended cut-off scores to screen for psychiatric disorders remained the same in a replication study.

Method. Six hundred and seventy psychiatric out-patients presenting for treatment were evaluated with a semi-structured diagnostic interview after completing the PDSQ.

Results. Based on receiver operating curve analysis, the PDSQ performed as well in the replication sample as in the initial validation study. For nine of the 13 PDSQ subscales the recommended cut-off score in the replication study was the same as in the initial study. After combining the data from the two studies (n=1300) the mean sensitivity across the 13 PDSQ subscales was 87% and the mean negative predictive value was 97%.

Conclusions. The PDSQ is a diagnostic aid designed to improve the efficiency of conducting initial diagnostic evaluations. From a clinical perspective it is important that a screening tool have good sensitivity so that most cases are detected, and high negative predictive value so that most non-cases on the measure are indeed non-cases. The results of this second large validation study indicate that most of the PDSQ subscales achieved this goal.

Background. The purpose of this study was to present 12-month and lifetime estimates of the prevalence, sociodemographic and clinical correlates, and psychiatric co-morbidity of DSM-IV cannabis abuse and dependence.

Method. Data were derived from a large nationally representative survey (n=43093) of US adults.

Results. The prevalence of 12-month and lifetime DSM-IV cannabis abuse (1·1% and 7·2%) exceeded the corresponding rates of cannabis dependence (0·3% and 1·3%). Being male, Native American, widowed/separated/divorced, and residing in the West increased the odds whereas being Black, Asian or Hispanic decreased the odds of cannabis abuse and dependence. Cannabis dependence was significantly associated with low income. Ages of onset for both cannabis use disorders occurred in adolescence and the majority of individuals with these disorders remained untreated. Co-morbidity was high between cannabis use disorders and other Axis I and II disorders.

Conclusions. Cannabis use disorders continue to present a widespread and serious personal and public health problem. Native Americans were found to have high rates of cannabis use disorders, warranting closer attention to the mental health needs of this subgroup. Associations between cannabis abuse and dependence and Axis I and II disorders were strong, signaling the need for more comprehensive assessment of individuals with cannabis use disorders. Further controlled treatment studies are needed, especially among co-morbid individuals, in view of growing evidence of the adverse personal, medical and societal impacts of cannabis use disorders in the USA.

Background. Deliberate self-harm (DSH) may be associated with increased risk of death from a variety of causes, not just suicide.

Method. A follow-up study of 11583 DSH patients who presented to a general hospital over a 20-year period was conducted to examine risk of death from a range of causes during a follow-up period of between 3 and 23 years. Deaths were identified through national death registries. Expected numbers of deaths were calculated from national death statistics.

Results. The number of deaths (1185, 10·2%) was 2·2 times the expected number, the excess being significantly greater in males than females. Suicides were 17 times more frequent than expected and undetermined causes of death and accidental poisonings 15 times more frequent. Significantly more than expected numbers of deaths from most natural causes were found, including respiratory disease, circulatory, neurological, endocrine, digestive, skin and musculoskeletal and connective tissue disorders, and symptoms, signs and ill-defined conditions. Deaths due to accidents other than poisoning were more frequent than expected in both genders and homicides more frequent in males.

Conclusions. In addition to increased risk of suicide, DSH patients are at increased risk of dying from a wide range of other causes. Possible explanations include lifestyle factors, physical disorders contributing to initial risk of DSH, and social disadvantage. The findings are relevant to clinical management and evaluation of outcome and health-care costs associated with DSH.

Background. Emotional Stroop tasks have shown attention biases of clinical populations towards stimuli related to their condition. Asperger Syndrome (AS) is a neuropsychiatric condition with social and communication deficits, repetitive behaviours and narrow interests. Social deficits are particularly striking, including difficulties in understanding others.

Method. We investigated colour-naming latencies of adults with and without AS to name colours of pictures containing angry facial expressions, neutral expressions or non-social objects. We tested three hypotheses: whether (1) controls show longer colour-naming latencies for angry versus neutral facial expressions with male actors, (2) people with AS show differential latencies across picture types, and (3) differential response latencies persist when photographs contain females.

Results. Controls had longer latencies to pictures of male faces with angry compared to neutral expressions. The AS group did not show longer latencies to angry versus neutral expressions in male faces, instead showing slower latencies to pictures containing any facial expression compared to objects. When pictures contained females, controls no longer showed longer latencies for angry versus neutral expressions. However, the AS group still showed longer latencies to all facial picture types, compared to objects, providing further evidence that faces produce interference effects for this clinical group.

Conclusions. The pictorial emotional Stroop paradigm reveals normal attention biases towards threatening emotional faces. The AS group showed Stroop interference effects to all facial stimuli regardless of expression or sex, suggesting that faces cause disproportionate interference in AS.

Background. Persistent fatigue is strongly associated with functional status and can lead to absenteeism and work disability. Despite several prognostic studies on chronic fatigue, little attention has been paid to occupational outcomes.

Method. A total of 127 fatigued employees on sick leave were followed-up after 4 years to determine long-term predictors of work disability, fatigue caseness and chronic fatigue syndrome (CFS)-like caseness. Measures included fatigue, physical functioning, illness attributions, psychological problems and emotional exhaustion.

Results. Thirty-three participants (26%) were receiving work disability benefits at the 4-year follow-up. Older age and lower levels of physical functioning predicted work disability. Weaker psychological attributions and lower levels of physical functioning were predictors of fatigue caseness. CFS-like caseness was predicted by female gender and lower levels of physical functioning. Self-reported physical functioning remained a strong and statistically significant determinant of work disability [odds ratio (OR) 0·45, 95% confidence interval (CI) 0·24–0·87] and CFS-like caseness (OR 0·20, 95% CI 0·09–0·43) after controlling for confounders.

Conclusions. This study suggests that physical functioning plays an important role in the persistence of fatigue complaints and work disability in employees on sick leave. The course of fatigue is a complex process, and exploring temporal relationships between fatigue, functional status and work status in future research could provide valuable information for the improvement of fatigue management.

Background. Common mental disorder prevalence decreases substantially around the conventional retirement age for men in the UK, but trends for older women are more continuous. Prevalence changes in depression and anxiety around retirement are less clear, as is the role of risk factors. The aim of this study was to establish whether work status, age or other known risk factors account for the reduced prevalence of depressive episode and anxiety disorder around retirement ages for men and for women.

Method. The British Psychiatric Morbidity Survey (BPMS) 2000 was analysed, including 1875 men and 2253 women aged 45–75 years. Diagnoses were from the Revised Clinical Interview Schedule (CIS-R). Logistic models were adjusted for sociodemographic factors, social network, work status, life events, physical illness and disability.

Results. There are marked reductions in the prevalence of depressive episode after 60 years for women [60% lower prevalence, 95% confidence interval (CI) 40–80] and 65 years for men (90% lower prevalence, 95% CI 70–100), compared to the youngest age groups. For anxiety disorder, the reduction in prevalence was 80% (95% CI 60–90) for men and 40% (95% CI 20–60) for women. In fully adjusted multivariate models, the strong association between diagnoses and age groups remained, for both genders. Work status was a significant factor for men but not for women.

Conclusion. There is a discontinuity in the prevalence of depressive episode for both men and women, coinciding with statutory retirement ages. No studied risk factor reduced the associations between age group and disorders. This population scale recovery may provide a model for understanding non-genetic factors.

Background. Some doctors who initially choose psychiatry do not pursue it as a long-term career. The study seeks to identify reasons for leaving psychiatry.

Method. Postal questionnaire survey of UK medical graduates of 1988, 1993, 1996 and 1999 identified as having left psychiatry; for comparison, doctors who left general practice or trauma and orthopaedics.

Results. Response rate was 74% (572/778); 488 respondents satisfied study criteria (59 psychiatry, 318 general practice, 111 trauma and orthopaedics). The speciality's poor public image, perceived lack of respect from medical peers, perceived threat of violence from patients, under-resourcing and low morale were problems for psychiatry leavers. Job stress, self-assessed unsuitability, and concerns about the lack of evidence-based treatments also influenced decisions to leave psychiatry.

Conclusions. Early exposure to psychiatry may help trainees assess their suitability. Negative perceptions of workforce issues (e.g. low morale) and of clinical issues (e.g. perceived lack of ability to improve prognosis) need addressing to increase retention.