Little is known about the outcome of common mental disorders (CMD) in primary care attenders in low income countries.

Two and 12 month (T1 and T2) follow-up of a cohort of cases of CMD (n=199) recruited from primary health, traditional medical practitioner, and general practitioner clinics in Harare, Zimbabwe. The Shona Symptom Questionnaire (SSQ) was the measure of caseness.

The persistence of case level morbidity was recorded in 41% of subjects at 12 months. Of the 134 subjects interviewed at both follow-up points, 49% had recovered by T1 and remained well at T2 while 28% were persistent cases at both T1 and T2. Higher SSQ scores, a psychological illness model, bereavement and disability predicted a poor outcome at both times. Poorer outcome at T1 only was associated with a causal model of witch-craft and an unhappy childhood. Caseness at follow-up was associated with disability and economic deprivation.

A quarter of cases of CMD were likely to be ill throughout the 12 month follow-up period. Targeting risk groups for poor outcome for interventions and policy interventions to reduce the impact of economic deprivation may provide a way of tackling CMD in primary care in low income countries.

People with schizophrenia are at high risk of psychotic relapse. The purpose of this study was to evaluate the predictive validity and temporal link of early signs to this.

A study sample of 60 out-patients with schizophrenia was examined every second week over a period of six months. The study design included self-reporting (Early Signs Scale) and objective assessment (General Psychopathology of Positive and Negative Symptom Scale) of behavioural and phenomenological changes (early signs). Criterion cut-off points were based on a comparison to the subjects' individual baseline scores.

Twenty-seven subjects (45%) experienced a relapse. Composite increased score ($ 10 points) of self-reported/objectively assessed early signs predicted the relapse with a sensitivity of 81% and a specificity of 79%. Thus the predictive validity of early signs of relapse was considerable, particularly self-reporting of early signs of relapse: sensitivity 74% and specificity 79%. The inclusion of objective assessment added only marginally to the prediction. Early signs were detected most often (70%) within the four weeks immediately before the individuals' relapse.

Psychotic relapse is most often preceded by early signs. Clinical practice should integrate this knowledge by an ongoing monitoring including self-reporting.

In recent years there has been a shift to ‘community care’ and the introduction of several ‘atypical’ antipsychotic drugs. We report the impact of these changes.

In Nithsdale, Dumfries and Galloway, Scotland, the population of patients with schizophrenia was identified in 1996. This census replicated a study carried out in 1981. The population with schizophrenia were compared on clinical and social variables. The whereabouts in 1996 of the 1981 population was determined.

In comparison with the 1981 population, more patients in 1996 had positive, negative and non-schizophrenic symptoms. More showed tardive dyskinesia. Social adjustment had not changed. They had spent less time in hospital; fewer (13%) were living with their parents; and fewer (8%) were employed. By 1996, 35% of the 1981 cohort had died (standardised mortality rate male – 154, female – 162).

The mental health of a community of people with schizophrenia living in a rural area in 1996 was poorer than in 1981.

Since people with chromosome 22q11 deletion (CATCH 22 syndrome) have unexpectedly high incidence of major psychosis it has been suggested that 22q area might be involved in the pathogenesis of schizophrenia and bipolar disorders.

A single case report.

A 32-year-old male patient with CATCH 22 syndrome and schizophrenia had extensive midline anomalies of the brain in the regions relevant to psychotic disorders.

22q11-dependent abnormalities in the midline structures of the brain may cause dysfunction in the limbic system and interfere with the interhemispheric information exchange thus predisposing people with CATCH 22 syndrome to psychotic disorders.

Elderly people with paranoid symptoms are a taxing group for medical and social services, but studies of the prevalence of these symptoms in the general elderly population are rare. This study aimed to estimate the community prevalence and to identify some associated variables.

A community sample of 1420 elderly people, was extensively examined by nurses and physicians.

Paranoid ideation was found in 6.3% of the sample. The prevalence in people with cognitive dysfunction (n=381, 12.1%) was higher than in those without (n=1039, 2.6%). Once cognitive impairment had been controlled the associated variables were: being divorced, being female, having depressive symptoms, using psychotropic drugs, having no friends or visitors, using community care and being an immigrant.

Paranoid symptoms in this elderly population were associated most strongly with cognitive impairment. Other associated variables pointed to a higher level of social isolation than others in the community.

Little is known of the behavioural adjustment of children of postnatally depressed mothers. Previous studies have relied on maternal reports, and have produced inconsistent findings.

In a prospective, longitudinal study of the five-year-old children of a community sample of postnatally depressed and well women, evidence was collected concerning the children's adjustment in the context of school, teachers being asked to complete questionnaires after the children had finished their first term.

Family social class and the child's gender had the most pervasive influences on adjustment. However, both postnatal and recent maternal depression were associated with significantly raised levels of child disturbance, particularly among boys and those from lower social class families.

The findings indicate a persistent effect of postnatal depression on child adjustment. They highlight the need for resources devoted to supporting mothers of young children and particularly routine screening and treatment for postnatal mood disorder.

The aim was to analyse the role of psychiatric disorders in sick-leave in different sick-leave diagnoses.

A stratified population-based sample of women (n=292) in Göteborg were interviewed, and diagnoses were made according to DSM–III–R. Sick-leave data, including diagnoses, were obtained for two years.

Women with psychiatric disorders had an increased number of sick-leave spells and sick-leave days in all the sick-leave diagnostic groups. The largest differences between the two groups of women were found in mental disorders, diseases of the locomotor system and gastro-intestinal diseases. The association between psychiatric disorders and sick-leave was strongest in older age groups.

Unrecognised psychiatric disorders associated with an increased number of medical complaints and visits can be an important factor in the increase in sick-leave.

The present study investigated histories of prior psychiatric treatment in cases of sudden death reported to the coroner.

A matching survey linked the register of deaths reported to the coroner with a comprehensive statewide psychiatric case register covering both inpatient and community-based services.

Sudden death was five times higher in people with histories of psychiatric contact. Suicide accounted for part of this excess mortality but deaths from natural causes and accidents were also elevated. Schizophrenic and affective disorders had similar suicide rates. Comorbid substance misuse doubled the risk of sudden death in affective and schizophrenic disorders.

The rates of sudden death are sufficiently elevated to raise questions about current priorities in mental health care. There is a need both for greater attention to suicide risk, most notably among young people with schizophrenia, to the early detection of cardiovascular disorders and to the vigorous management of comorbid substance misuse.

Selective serotonin reuptake inhibitors are currently the most widely prescribed antidepressant drugs. There are only four published studies of breast-feeding mothers and their infants in which the mothers were taking fluoxetine.

Four mothers who took fluoxetine and their breast-fed infants were studied. Samples of plasma, breast-milk and urine were taken from the mothers and of plasma and urine from infants for assays of drug and metabolite concentrations. Bayley Scales of Infant Development were repeatedly used to assess cognitive and psychomotor development of the infants.

Fluoxetine and norfluoxetine were detected in all samples of maternal plasma (range of total concentration 138–427 ng/ml) and in breast-milk (range 39–177 ng/ml). Amounts of both fluoxetine and norfluoxetine in infants' plasma and urine were below the lower limit of detection. All infants were observed to be developing normally and showed no abnormal findings on neurological examination.

Much larger databases are needed but these four cases do not provide any evidence to suggest that women who are maintained on therapeutic doses of fluoxetine should discontinue breast-feeding their infants if they wish to breast-feed.

Previous studies have suggested that the risk for psychosis, especially affective psychosis, is highly increased during the first 30 days after delivery. The aim of our study was to replicate these findings.

LinkingThe Danish Medical Birth Register and The Danish Psychiatric Central Register from 1 January 1973 to 31 December 1993 revealed 1253 admissions diagnosed as psychosis within 91 days after delivery. The admission rate after delivery was compared with the admission rate among non-puerperal women in the general Danish female population.

The relative risk of all admissions was only slightly increased, RR=I.09 (95% C11.03–1.16). The admission rate concerning first admissions was highly increased, RR=3.21 (95% CI 2.96–3.49) whereas the admission rate concerning readmissions was reduced, RR=0.66 (95% CI 0.61–0.72).

Childbirth is a strong risk factor for first admission with psychosis, but the risk may be less increased than previously assumed.

Velo-cardio-facial syndrome (VCFS), a syndrome of multiple congenital abnormalities including characteristic dysmorphology, congenital heart defects and learning disability is associated with small interstitial deletions of chromosome 22qll. We tested the hypothesis that VCFS may be significantly under-diagnosed by screening a learning-disabled population for chromosome 22qll deletions.

Two hundred and sixty-five people with learning disability residing in two learning disability hospitals in South Wales were reviewed. They were selected for inclusion in the study if they fulfilled any of the following criteria: psychotic disorder (schizophrenia or affective disorder), family history of psychotic disorder, cleft palate and/or lip, congenital heart disease, broadly defined facial dysmorphism or a history of hypocalcaemia. Fluorescence in situ hybridisation studies were performed on 74 selected individuals.

Cytogenetic analysis revealed that two people demonstrated a previously undetected chromosome 22qll deletion. A third person demonstrated a previously undetected cytogenetically visible deletion on chromosome 15.

VCFS appears to be aetiologically significant in a proportion of individuals with idiopathic learning disability especially in those where psychosis is associated with mild learning disability. We suggest that clinicians should consider a chromosome 22qll deletion in people who meet selection criteria.

We evaluated the utility of the Chinese version of the Edinburgh Postnatal Depression Scale (EPDS) and measured the prevalence of major depression six weeks after confinement among Chinese women in Hong Kong.

A prospective cohort of 145 women completed the EPDS, the 12-item General Health Questionnaire (GHQ) and the Beck Depression Inventory (BDI) six weeks after giving birth. They were then assessed with the Structured Clinical Interview for DSM–III–R, non-patient version (SCID–NP) to establish psychiatric diagnosis. The criterion validity of EPDS was tested against this clinical diagnosis, and the concurrent validity against the GHQ and BDI scores was also evaluated. The internal consistency of the scales was measured by Cronbach's α coefficient.

The Chinese EPDS had satisfactory psychometric properties and a cut-off score of 9/10 is recommended for screening depressive illness in a general postnatal population. At six weeks postpartum, 5.5% of the study population suffered from major depression.

The Chinese EPDS will be useful for screening for postnatal depression.

Marry nightmare sufferers do not consult a health care professional. Though behaviour and cognitive therapy can help, they have not been tested as a self-treatment method at home using a manual.

One hundred and seventy adults with primary nightmares were randomised to four weeks' self-exposure or self-relaxation at home using manuals posted to them, or to a waiting-list as a control group for four weeks. Individuals recorded nightmare frequency and intensity in four-week diaries.

At one- and six-month follow-up, the self-rated nightmare frequency felt more significantly in exposure subjects than relaxation or waiting-list subjects. The self-exposure group had the most drop-outs but remained superior in an over-cautious intent-to-treat analysis. The individuals' partners confirmed the superiority of self-exposure to self-relaxation at one- and six-month follow-up.

Recurrent nightmare sufferers improved more with self-exposure manuals than with self-relaxation manuals or by being on a waiting-list. Self-exposure may be needed for longer than four weeks in order to reduce nightmare intensity as well as frequency. Despite a high drop-out rate, some sufferers of other conditions may benefit from self-treatment manuals.

African–Caribbean men are over-represented in psychiatric and forensic services and in the prison population. A failure of community services to engage mentally ill African–Caribbean men and their presentation through the criminal justice system culminates in a repeated pattern of forensic service and criminal justice system contact.

We carried out a cross-sectional survey during a one-year period of a sample of potentially mentally ill men remanded to HMP Brixton in south London. Men were interviewed to establish their place of birth, first language, socio-demographic profile, ethnicity, psychiatric diagnosis, levels of alcohol and substance misuse, criminality, violence involved in their index offence, past psychiatric and forensic contacts and outcome of court appearance.

Two hundred and seventy-seven men were interviewed. In comparison with White men, African–Caribbean men were more often diagnosed as having schizophrenia and were more often sent to hospital under a mental health act order. African–Caribbean men were remanded in custody despite more stable housing conditions and more favourable indices of lifetime criminality, substance misuse and violence.

Community services, including diversion schemes, should be especially sensitive to African–Caribbean men with schizophrenia who ‘fall out of care’, who are not diverted back into care and are therefore unnecessarily remanded.

Attachment theory argues that psychological development and functioning are affected by our earliest attachments to care-givers. Failed or pathological attachment in childhood may give rise to repetition of maladaptive attachment patterns in adulthood.

Analysis of therapeutic relationships in the light of attachment theory.

Relationships between patients and both psychiatric care-givers and institutions may resemble attachment relationships.

An attachment perspective may be useful for understanding common behavioural disturbances in general psychiatric settings, and support the use of clinical strategies which focus on containment of arousal and the management of anxiety states.

The aetiology of treatment-resistant major depression is little understood; its apparent intractability may reflect brain abnormality.

Magnetic resonance images of the brains of 20 subjects with major depression lasting for two years or more were compared with 20 healthy control subjects and 20 other subjects who had completely recovered from depression. Subjects were individually matched for age, gender, years of education and premorbid IQ. Grey matter was segmented from the images, and compared between groups on a voxel-by-voxel basis.

Subjects with chronic depression showed reduced grey matter density in the left temporal cortex including the hippocampus. There was also a trend for reduction in the right hippocampus. Left hippocampal grey matter density was correlated with measures of verbal memory, supporting the functional significance of the observed magnetic resonance imaging changes.

Our results potentially challenge the accepted view of depression as a functional and fully reversible illness, implying instead that more permanent brain changes may be associated with chronicity. Confirmatory longitudinal and prospective studies are required to determine whether these differences pre-date the onset of depression or are the result of the chronic illness process or its treatment.

Several studies have explored serotonin (5-HT) transmission in people with anorexia nervosa, but their results have been inconsistent.

According to a double-blind placebo-controlled design, plasma prolactin response to the specific serotonergic probe d-fenfluramine was investigated in 10 underweight and two normal-weight women with anorexia, and in 12 age-matched healthy females. Eating-related psychopathology, depressive and obsessive-compulsive symptoms, and aggressiveness were measured by appropriate rating scales.

Compared with healthy control subjects, the women with anorexia showed reduced baseline prolactin and oestrogen levels and increased basal Cortisol concentrations. The prolactin response to d-fenfluramine was blunted and did not correlate with psychopathological measures.

These results support a dysfunction of 5-HT transmission in anorexia nervosa. This dysfunction does not seem to be related to concomitant depressive or obsessive-compulsive symptoms or to the level of aggressiveness of the patients.