Prenatal loss, the death of a fetus/child through miscarriage or stillbirth, is associated with significant depression and anxiety, particularly in a subsequent pregnancy.

This study examined the degree to which symptoms of depression and anxiety associated with a previous loss persisted following a subsequent successful pregnancy.

Data were derived from the Avon Longitudinal Study of Parents and Children cohort, a longitudinal cohort study in the west of England that has followed mothers from pregnancy into the postnatal period. A total of 13 133 mothers reported on the number and conditions of previous perinatal losses and provided self-report measures of depression and anxiety at 18 and 32 weeks' gestation and at 8 weeks and 8, 21 and 33 months postnatally. Controls for pregnancy outcome and obstetric and psychosocial factors were included.

Generalised estimating equations indicated that the number of previous miscarriages/stillbirths significantly predicted symptoms of depression (β = 0.18, s.e. = 0.07, P<0.01) and anxiety (β = 0.14, s.e. = 0.05, P<0.01) in a subsequent pregnancy, independent of key psychosocial and obstetric factors. This association remained constant across the pre- and postnatal period, indicating that the impact of a previous prenatal loss did not diminish significantly following the birth of a healthy child.

Depression and anxiety associated with a previous prenatal loss shows a persisting pattern that continues after the birth of a subsequent (healthy) child. Interventions targeting women with previous prenatal loss may improve the health outcomes of women and their children.

It has been proposed that schizophrenia is associated with underactivity of brain glutamatergic neurotransmission, especially at the level of the N-methyl-D-aspartate (NMDA) subtype of glutamate receptor. Glycine potentiates NMDA receptor-mediated neurotransmission, indicating that it may serve as an effective therapeutic agent in the treatment of schizophrenia.

Eleven treatment-resistant patients with chronic schizophrenia completed a double-blind placebo-controlled, six-week, randomly assigned, crossover treatment trial of 0.8 g/kg body weight/day of glycine, added to their prior antipsychotic treatment.

Glycine was well tolerated, resulted in significantly increased serum glycine levels and induced a mean 36 (7%) reduction in negative symptoms (P < 0.0001). Significant improvments were also induced in depressive and cognitive symptoms. The greatest reduction in negative symptoms was registered in the patients who had the lowest baseline serum glycine levels.

These results extend previous findings and suggest an additional approach to the pharmacotherapy of negative symptoms and cognitive deficits in schizophrenia.

More people are presenting with mild cognitive impairment (MCI), frequently a precursor to dementia, but we do not know how to reduce deterioration.

To systematically review randomised controlled trials (RCTs) evaluating the effects of any intervention for MCI on cognitive, neuropsychiatric, functional, global outcomes, life quality or incident dementia.

We reviewed 41 studies fitting predetermined criteria, assessed validity using a checklist, calculated standardised outcomes and prioritised primary outcome findings in placebo-controlled studies.

The strongest evidence was that cholinesterase inhibitors did not reduce incident dementia. Cognition improved in single trials of: a heterogeneous psychological group intervention over 6 months; piribedil, a dopamine agonist over 3 months; and donepezil over 48 weeks. Nicotine improved attention over 6 months. There was equivocal evidence that Huannao Yicong improved cognition and social functioning.

There was no replicated evidence that any intervention was effective. Cholinesterase inhibitors and rofecoxib are ineffective in preventing dementia. Further good-quality RCTs are needed and preliminary evidence suggests these should include trials of psychological group interventions and piribedil.

C.L. has received grant support (research or continuing medical education) from NIMH, NIA, Associated Jewish Federation of Baltimore, Weinberg Foundation, Forest, GlaxoSmithKline, Eisai, Pfizer, AstraZeneca, Lilly, Ortho-McNeil, Bristol-Myers Squibb, Novartis, National Football League (NFL), Elan, Functional Neuromodulation; and has been a consultant/advisor to AstraZeneca, GlaxoSmithKline, Eisai, Novartis, Forest, Supernus, Adlyfe, Takeda, Wyeth, Lundbeck, Merz, Lilly, Pfizer, Genentech, Elan, NFL Players Association, NFL Benefits Office, Avanir, Zinfandel, Bristol-Myers Squibb; and received honorarium or travel support from Pfizer, Forest, GlaxoSmithKline, Health Monitor.

From a first clinical description of a complete resident sample of special (high security) hospital patients, we examined the association between mental disorder and violence.

A record survey of all 1740 patients resident at any time between 1 January and 30 June 1993. inclusive, and, for most, the official criminal record.

1015 patients (58%) had functional psychosis, one-quarter of whom also had an independent personality disorder: 461 (26%)had personality disorders uncomplicated by psychosis, and 264 (16%) had learning disabilities. Pre-admission substance misuse, which was probably under-recorded, had been most common among those with psychosis and an independent personality disorder. Less than 10% had never been convicted of a criminal offence, although 25% had been admitted directly from other hospitals. Direct personal violence was more common among men, and fire-setting among women. Schizophrenia was most strongly associated with personal violence. More than 75% of those with a psychosis were recorded as being driven to offend by their delusions. In the absence of delusions, hallucinations had no such effect.

For people with personality disorder better clinical descriptions seem essential. For people with a pure psychosis, as symptoms were usually a factor driving the index offence, treatment appears as important for public safety as for personal health.

The aim was to assess the effect of a flexible dose of paroxetine, compared with clomipramine and placebo, in obsessive-compulsive disorder (OCD).

In a multinational randomised study, 406 subjects with OCD of at least six months duration received double-blind mediation for up to 12 weeks. Doses were adjusted according to therapeutic effect and side-effects. Primary efficacy measures were the Yale–Brown Obsessive–Compulsive Scale and the National Institute of Mental Health Obsessive–Compulsive Scale. Secondary efficacy measures were the Montgomery–åsberg Depression Rating Scale, Symptom Check-List (90), Clinical Global Impression, and Patients' Global Evaluation.

Paroxetine was significantly more effective than placebo, and of comparable efficacy to clomipramine. Paroxetine had significantly superior tolerability to clomipramine on three measures: CGI efficacy index, anticholinergic adverse events, and adverse events leading to withdrawal.

Paroxetine is as effective as clomipramine in the treatment of OCD. The comparable efficacy and better tolerability of paroxetine suggest that it would be an appropriate treatment for OCD.

There is a lack of research on the possible contribution of a structured risk assessment to the reduction of aggression in psychiatric in-patient care

To assess whether such risk assessments decrease the incidence of violence and coercion

A cluster randomised controlled trial was conducted with 14 acute psychiatric admission wards as the units of randomisation, including a preference arm. The intervention comprised a standardised risk assessment following admission with mandatory evaluation of prevention in high-risk patients

Incidence rates decreased substantially in the intervention wards, whereas little change occurred in the control wards. The adjusted risk ratios suggest a 41% reduction in severe aggressive incidents and a 27% decline in the use of coercive measures. The severity of aggressive incidents did not decrease

Structured risk assessment during the first days of treatment may contribute to reduced violence and coercion in acute psychiatric wards

Smoking is disproportionately prevalent among people with psychiatric illness.

To investigate smoking as a risk factor for major depressive disorder.

A population-based sample of women was studied using case–control and retrospective cohort study designs. Exposure to smoking was self-reported, and major depressive disorder diagnosed using the Structured Clinical Interview for DSM–IV–TR (SCID–I/NP).

Among 165 people with major depressive disorder and 806 controls, smoking was associated with increased odds for major depressive disorder (age-adjusted odds ratio (OR)=1.46, 95% CI 1.03–2.07). Compared with non-smokers, odds for major depressive disorder more than doubled for heavy smokers (>20 cigarettes/day). Among 671 women with no history of major depressive disorder at baseline, 13 of 87 smokers and 38 of 584 non-smokers developed de novo major depressive disorder during a decade of follow-up. Smoking increased major depressive disorder risk by 93% (hazard ratio (HR)=1.93, 95% CI 1.02–3.69); this was not explained by physical activity or alcohol consumption.

Evidence from cross-sectional and longitudinal data suggests that smoking increases the risk of major depressive disorder in women.

Although a number of functional imaging studies are in agreement in suggesting orbitofrontal and subcortical hyperfunction in the pathophysiology of obsessive–compulsive disorder (OCD), the structural findings have been contradictory.

To investigate grey matter abnormalities in patients with OCD by employing a novel voxel-based analysis of magnetic resonance images.

Statistical parametric mapping was utilised to compare segmented grey matter images from 25 patients with OCD with those from 25 matched controls.

Increased regional grey matter density was found in multiple cortical areas, including the left orbitofrontal cortex, and in subcortical areas, including the thalamus. On the other hand, regions of reduction were confined to posterior parts of the brain, such as the left cuneus and the left cerebellum.

Increased grey matter density of frontal–subcortical circuits, consonant with the hypermetabolic findings from functional imaging studies, seems to exist in patients with OCD, and cerebellar dysfunction may be involved in the pathophysiology of OCD.

Orbitofrontal cortex dysfunctions have been frequently documented in people with substance use disorders. The exact role of this cortical region, however, remains unspecified.

To assess the functionality of the orbitofrontal cortex in people with substance use disorders.

Reports of studies using behavioural decision-making tasks and/or neuroimaging techniques to investigate orbitofrontal cortex functioning in cases of substance misuse were reviewed. Studies focusing exclusively on tobacco-smoking and gambling were excluded.

Fifty-two research articles were evaluated. Most studies showed significant deficits in decision-making in people with substance use disorders. A consistent finding in the neuroimaging studies was hypoactivity of the orbitofrontal cortex after detoxification. The association between hyperactivity of this region and craving or cue reactivity was not consistent across studies.

The orbitofrontal cortex has an important role in addictive behaviours. Further studies are needed to elucidate the underlying neuronal substrates of cue reactivity, craving and decision-making, and the implications for treatment and relapse prevention.

The utility of the Hospital Anxiety and Depression Scale (HADS) as a screening instrument for anxiety and depressive disorders in non-psychiatric units (medical & surgical wards; gynaecology & antenatal clinics of a teaching hospital) and a community sample in Nigeria was investigated.

A two-stage screening procedure was employed. This involved the use of GHQ–12/GHQ–30 and HADS against the criteria of a standardised (PSE schedule) psychiatric interview, with psychiatric diagnosis assigned in accordance with ICD–9 criteria.

Sensitivity for the anxiety sub-scale ranged from 85.0% in the medical and surgical wards to 92.9% in the ante-natal clinic, while sensitivity for the depression sub-scale ranged from 89.5% in the community sample to 92.1% in the gynaecology clinic. Specificity for the anxiety sub-scale ranged from 86.5% in the gynaecology clinic to 90.6% in the community sample, while specificity for the depression sub-scale ranged from 86.6% in the medical and surgical wards to 91.1 % in the ante-natal clinic and community sample. Misclassification rates ranged from 9.9% in the community sample to 13.2% in the medical and surgical wards. Relative Operating Characteristic (ROC) analyses showed the HADS and the GHQ–12 to be quite similar in ability to discriminate between cases (anxiety and depression) and non-cases.

The HADS is valid for use as a screening instrument in non-psychiatric units and although initially developed for use in hospital settings, it could be usefully employed in community settings of developing countries to screen for mental morbidity.

Findings in developmental psychopathology suggest that traumatisation in childhood may increase the risk of both post-traumatic stress disorder (PTSD) and major depressive disorder, whereas traumatisation in adolescence is more likely to lead to elevated PTSD risk.

To estimate the impact of traumatisation in childhood or adolescence in a community sample.

A representative sample of 1966 young women from Dresden aged 18–45 years were interviewed for occurrence of traumatic events and the onset of PTSD and major depression. The sample was subdivided into a childhood trauma group (trauma up to age 12 years) and an adolescent trauma group (trauma from age 13 years).

A quarter of all participants reported traumatic events meeting the DSM AI criterion. In the childhood group conditional risks for PTSD and major depressive disorder were 17.0% and 23.3%, respectively, compared with risks of 13.3% and 6.5%, respectively, in the adolescent group. In 29% of those with PTSD, major depression was also present.

The risk of developing major depressive disorder after traumatisation in childhood is approximately equal to the risk of developing PTSD. After age 13 years, the risk of PTSD is greater than the risk of major depression after traumatisation.

The critical period hypothesis proposes that deterioration occurs aggressively during the early years of psychosis, with relative stability subsequently. Thus, interventions that shorten the duration of untreated psychosis (DUP) and arrest early deterioration may have long-term benefits.

To test the critical period hypothesis by determining whether outcome in non-affective psychosis stabilises beyond the critical period and whether DUP correlates with 8-year outcome; to determine whether duration of untreated illness (DUI) has any independent effect on outcome.

We recruited 118 people consecutively referred with first-episode psychosis to a prospective, naturalistic cohort study.

Negative and disorganised symptoms improved between 4 and 8 years. Duration of untreated psychosis predicted remission, positive symptoms and social functioning at 8 years. Continuing functional recovery between 4 and 8 years was predicted by DUI.

These results provide qualified support for the critical period hypothesis. The critical period could be extended to include the prodrome as well as early psychosis.

The hypothesis that Asperger's syndrome (AS) may go unrecognised in forensic populations was examined by ascertaining the prevalence in Broadmoor Special Hospital.

The entire male patient population was screened by examination of case notes. Identified cases were subject to the next stage of the study, which involved observation and interviewing of patients, and a semi-structured interview of key staff.

A prevalence of 1.5% (0.6% to 3.3%, 95% CI) was found. The addition of equivocal cases increased the prevalence to 2.3%.

The prevalence of AS in Broadmoor Hospital is greater than that reported for the general population.

British Journal of Psychiatry (1994), 165, 679–682

A comparison of the performance of the 5-item mental health dimension of SF–36 (MHI–5) with that of the 12-item General Health Questionnaire (GHQ–12) in a defined, non-patient population, using standard statistical tests.

A postal survey of 3000 patients aged 16–64 years was conducted. Patients were randomly selected from the practice lists of two general practices chosen to represent populations with different socio-economic characteristics.

Considerable evidence was found for the internal consistency of both instruments (Cronbach's α 0.91 and 0.84 for GHQ–12 and the MHI–5 respectively) and for their construct validity in terms of distinguishing between groups with measured health differences. Both instruments showed a significant difference in the mean scores for men and women. In contrast to the GHQ–12, no correlation was found between age and score for the MHI–5. Both instruments were equally sensitive to socio-economic characteristics and to levels of social support The scores on the two instruments were highly correlated (Spearman rank correlation – 0.73).

The MHI–5 has comparable psychometric performance to the GHQ–12, and can be used to measure and compare mental health in defined populations. Operational advantages of the MHI–5 over the GHQ–12 are that it is in the public domain, is part of a general health measure (SF–36) and is shorter.