Unipolar and bipolar patients with a chronic illness pattern were investigated to determine whether they experienced a higher number of life events prior to the onset of recurrent affective episodes.

The study participants consisted of 27 recovered bipolar patients, 24 recovered unipolar patients and 26 healthy control subjects. Life events and psychiatric status were assessed by bimonthly interviews over the period of one year using the Inventory for Recent Life Events and the Research Diagnostic Criteria.

In both unipolar and bipolar patients, analyses revealed no significant differences in the number of life events experienced, irrespective of whether the patients had presented with a depressive episode of at least minor intensity during the study (all P > 0.1). Specifically, an increase in marital problems was observed in bipolar patients prior to the onset of recurrent hypomanic and manic episodes (P=0.06).

The causal association between life events and the onset of depression, shown to be relevant in non-chronically depressed subjects, does not apply in chronic affective disorders. In addition, our results suggest that marital events have an impact on the onset of recurrent hypomanic and manic episodes.

The impact of major trauma on individuals with pre-existing and enduring mental health difficulties is poorly understood.

Twenty individuals with pre-existing and enduring mental health difficulties were assessed with the Clinician Administered Post Traumatic Stress Disorder Scale, the 28-item version of the GHQ, the Hospital Anxiety and Depression Scale, and the Impact of Event Scale between four and eight weeks after their involvement in a major coach accident.

Ten (50%) individuals satisfied the full DSM–IV criteria for a diagnosis of PTSD. The questionnaire scores indicated a high level of psychological suffering among the group. On dividing the sample into those individuals with previous diagnoses of anxiety or depressive disorders and those with a previous diagnosis of chronic schizophrenia, the schizophrenia group displayed less marked psychological sequelae on all measures.

There was a high incidence of early psychological sequelae among the group as a whole. Some diagnoses (e.g. depression and anxiety) may predispose to psychological sequelae while others (e.g. chronic schizophrenia) may not.

Literature and clinical experience suggest that some people experience atypical, complicated or pathological bereavement reactions in response to a major loss.

Three groups of community-based bereaved subjects – spouses (n=44), adult children (n=40), and parents (n=36) – were followed up four times in the 13 months after a loss. A 17-item scale of core bereavement times was developed and used to investigate the intensity of the bereavement response over time.

Cluster analysis revealed a pattern of bereavement-related symptoms approximating a syndrome of chronic grief in 11 (9.2%) of the 120 subjects. None of the respondents displayed a pattern consistent with delayed or absent grief.

In a non-clinical community sample of bereaved people, delayed or absent grief is infrequently seen, unlike chronic grief, which is demonstrated in a minority.

There is increasing awareness of the importance of psychopathological and behavioural changes in dementia and a need for an instrument to measure these features which achieves an appropriate compromise between brevity and breadth. We describe a newly developed 59-item instrument: the MOUSEPAD.

Reliability, sensitivity and validity were examined with 30 carers, each of whom was interviewed four times over six weeks.

For different symptom groups, kappa ranged from 0.43 to 0.93 for test–retest reliability, from 0.56 to 1.0 for inter-rater reliability, and from 0.43 to 0.67 for the validation study.

The scale may be useful as an outcome measure in drug trials, for correlating psychopathological and behavioural changes with post-mortem findings, and in epidemiological surveys.

This paper describes the 13 year course of illness in an epidemiologically defined and representative cohort of patients selected when they were experiencing their first episode of schizophrenia.

In a 13-year follow-up study of 67 patients with ICD–9 schizophrenia, identified in Nottingham in 1978–80, the course of illness (symptoms, disability and hospitalisation) was assessed using standardised instruments, applied at onset 1, 2, and 13 years. Time to first relapse and first readmission were calculated and plotted as survival curves and patients were assigned to the course types described by Ciompi.

The survival curves show that first relapses and first readmissions occur during the first five years. The amount of time spent in psychotic episodes and in hospital is greatest in the first year of follow-up, but stable thereafter. Social adjustment improves from entry to the study to the first follow-up year, but there is a small deterioration in social adjustment between 2 and 13 years.

The findings reported suggest that after the initial episode the course of schizophrenia is relatively stable. The data support neither concepts of progressive deterioration nor progressive amelioration. There was no evidence of a ‘late recovery’.

Four previous studies of homeless adults have yielded conflicting results regarding the presence of cognitive impairment.

A consecutive series of 80 roofless entrants to a hostel for homeless men were sampled and 62 (76%) completed a range of assessments, including measures of mental state, cognitive functions and substance use.

Estimated premorbid IQ (mean=96), current IQ (mean=84) and cognitive speed were significantly lower than the norm. There was a significant IQ drop in all diagnostic groups. IQ drop, but not current IQ, correlated with duration of rooflessness. Those with schizophrenia or alcohol problems were roofless for longest. Alcohol misuse did not correlate with IQ drop, excepting alcohol withdrawal symptoms in those with schizophrenia.

The hypothesis that low IQ is a risk factor for rooflessness is supported. However, length of rooflessness was more closely related to IQ drop than to current IQ, suggesting that some third factor may be affecting both rooflessness and intellectual functioning. Roofless men with schizophrenia or alcohol problems may be especially at risk of long-term rooflessness.

We compare and contrast some correlates of paternal and maternal depression after the live birth of a first child, as part of a longitudinal study.

Fifty-four first-time mothers attending obstetric services in Oporto, Portugal, and 42 of their husbands or partners participated in a longitudinal study of their mental health. All subjects were given a semi-structured clinical interview (SADS) at six months antenatally and at 12 months postnatally and sub-samples were interviewed at three months postnatally. At all these times all the mothers and fathers also completed a translated version of a self-rating scale for depression, the Edinburgh Postnatal Depression Scale (EPDS) and a series of other questionnaires and interviews to measure different psychosocial variables. Profiles of risk factors associated with depression in the first postnatal year were analysed by means of logistic regressions.

In the mothers, aside from a history of depression, the only other powerful predictor of postnatal depression was the mean objective negative impact score of life events. ‘Postnatal’ depression in fathers was associated with a history of depression in themselves and with the presence of depression in their wives or partners during pregnancy and soon after delivery.

Prevention and early treatment of depression in fathers may benefit not only themselves but also their spouses and their children.

This study is a three-month follow-up study in order to assess the short-term impact of traumatic stress among 53 Swedish survivors of the Estonia disaster.

A questionnaire consisting of general questions about conditions during and after the disaster and self-assessment by Post Traumatic Symptom Scale (PTSS–10), Impact of Event Scale (IES), Sense of Coherence–short version (SoC–12), and the DSM–IV list of dissociative symptoms of Acute Stress Disorder formulated as questions regarding individual reactions was distributed.

The response rate was 79.2% (n=42). The participants scored an average of 3.9 on PTSS–10, 28.5 on IES (‘intrusion’ and ‘avoidance’ subscales) and 62.8 on SoC–12, which shows elevated levels of post-traumatic stress reactions but a normal level of sense of coherence. The reported occurrence of dissociative symptoms during the disaster was as follows: emotional numbing in 43% of the survivors, reduction of awareness in 55%, derealisation in 67%, depersonalisation in 33%, and dissociative amnesia in 29%. Survivors scoring low in SoC scored significantly higher in both PTSS–10 and IES than those with high scores in SoC. All dissociative symptoms were predictive of post-traumatic reactions.

This study substantiates the importance of assessing dissociative symptoms during a life-threatening event as a possible predictor for later post-traumatic reactions and possible PTSD. The Sense of Coherence Scale may be useful as an instrument to sort out survivors at risk.

Depression has a reported mean prevalence of 24% in patients diagnosed with cancer. However, little systematic research on the efficacy of antidepressants in patients with cancer has been performed.

The efficacy and safety of mianserin were studied in 55 depressed women with breast cancer (stage I or II and without known metastases), in a randomised, double-blind, six-week, placebo-controlled study.

Statistically significant differences in the decrease in score from baseline on the Hamilton Rating Scale for Depression and the number of responders, favouring mianserin, were present after 28 and 42 days of treatment Significantly more placebo-treated patients prematurely terminated the study due to lack of efficacy while the safety profile of mianserin was similar to that of placebo.

Treatment with mianserin resulted in a significant improvement in depressive symptoms in cancer patients, and was well tolerated.

The purpose of this study was to investigate patterns of mental disorders comorbid with PTSD symptoms in young Israeli men exposed to combat.

Six hundred and seventeen subjects were selected via a general population sample and evaluated in a two-phase case-identification procedure, culminating in a modified SADS–L interview, administered by psychiatrists.

Major depressive disorder (OR=3.2), substance use disorders (OR=1.9) and personality disorders (OR=3.0) occurred more frequently in men reporting symptoms of PTSD than in men who had been under fire who did not report symptoms. With the possible exception of personality disorders, comorbid disorders did not constitute risk factors for PTSD. Comorbid PTSD and RDC disorders were associated with increased help-seeking.

The results suggest similar rates and types of PTSD comorbidity in Israeli war veterans as in veterans in the US assessed in general population studies, and are consistent with shared risk factors for PTSD and comorbid disorders.

Incidence rates of schizophrenia among UK African–Caribbeans have been reported as high. Various explanations including selective migration and genetic vulnerability have been proposed.

In one calendar year, all new cases of psychosis presenting to various psychiatric services in two clearly defined geographical catchment areas in Trinidad – one in the rural south and the other an urban area – were studied. Standardised diagnostic instruments were applied and information collected using WHO screening and measurement instruments.

A total of 56 cases were collected, giving an incidence rate of 2.2/1000 of broad schizophrenia with a rate of 1.6 for S+ schizophrenia.

These rates are similar to those from the WHO study in Honolulu and Aarhus, and much lower than the rates for African–Caribbeans in London. The cases were followed up for one year and the poor outcome rate for schizophrenia was 19%. The findings are discussed in a cross-cultural context and suggestions for future research made.

The police are the gatekeepers to the criminal justice system (CJS). It is agreed that where possible mentally ill people should be diverted to psychiatric care. The purpose of this investigation was to determine what factors were associated with the entry of obviously mentally ill people into the CJS.

The population of all detainees arrested in seven London police stations was observed to determine the presence of obvious mental illness. All detainees regarded as ill or known to have significant psychiatric histories were followed through the CJS to court disposal. Defendants diagnosed as psychotic by court liaison psychiatrists were identified and the circumstances of their arrest and detention examined.

Of all police detainees observed, 1.4% were found to be acutely ill. Diversion of obviously ill detainees was common practice. The factor most strongly associated with entry to the CJS was the presence of violence at time of arrest. Other factors were the persistence of (petty) offending and the operation of court warrants issued as a result of the person's failure to appear at court when required to do so.

Both police and courts are well aware of the inappropriateness of custody for acutely ill people and efforts are made to divert such people out of the CJS. Persistent petty offenders are often being recycled from the street to police station to court and back to the street without the benefit of care. A dedicated facility is recommended in central London to meet this need.

In community mental health care, knowledge about costs of care is very limited. Only few studies have related costs to outcome measures.

This German study assesses the cost of psychiatric care of 66 schizophrenic patients during one year of living in the community. Predictors of high cost were identified.

The average cost of comprehensive community care of one patient of the cohort was US$ 353 per week. This was only 43% of the cost of constant long-term care in a psychiatric hospital. Significant predictors of total cost of community care were the number of rehabilitative problems at the beginning and at the end of the study period, the type of accommodation before index hospitalisation and the gender of patients.

Results must be understood in terms of the characteristics of the special patient group and the catchment area we studied and are of high relevance in planning future care.

The paper describes the development of an index of the relative need for psychiatric services for the purposes of distributing NHS funds in England.

The study is based on an empirical analysis of all psychiatric in-patient completed episodes in England in 1991/92. Any index of need should be independent of the effect of variations in health care supply on the use of psychiatric services. In order to disentangle the influences of supply from social and clinical determinants of utilisation, two stage least squares regression and multilevel modelling techniques were used.

The outcome was an index comprising six health and socio-economic variables. This is now being used by the NHS Executive to distribute about £2.2 billion of annual NHS expenditure for psychiatric services between English health authorities.

It is shown that the index is much more sensitive to needs and therefore more redistributive than the previous index of need used in the NHS.

Depressed patients are often characterised by marital distress, but few studies investigate the effects of marital therapy on depressed mood and relationship dysfunction.

Twenty-seven depressed patients experiencing marital distress were randomly assigned to either individual behavioural–cognitive therapy or marital therapy. The individual treatment condition focused on depressed mood, behavioural activity and dysfunctional cognitions, whereas in the marital condition the partner was involved in the treatment and the focus was on the communication process in the marital relationship. MANOVAs revealed that treatment led to statistically significant improvements in depressed mood, behavioural activity and dysfunctional cognitions, an increase in relationship satisfaction and improvement of communication in patients and spouses. A significant interaction effect was found, showing that marital therapy had more impact on relationship variables than the individual treatment.

Both individual cognitive–behaviour therapy and marital therapy lead to less depressive complaints, and both treatment conditions have a positive effect on the relationship, although the effect on the relationship is significantly stronger in couples who were treated by marital therapy compared with patients who were treated individually.

The application of cognitive therapy (CT) to psychosis is currently being developed in the UK. This paper reports a trial of CT in acute psychosis with the objective of hastening the resolution of positive symptoms and reducing residual symptoms.

Of 117 patients with acute non-affective psychosis, 69 satisfied inclusion criteria and 40 proceeded to stratified randomisation. The experimental intervention involving individual and group CT was compared with a group receiving matched hours of therapist input providing structured activities and informal support; routine pharmacotherapy was provided by clinicians blind to group allocation. Patients were monitored weekly using self-report and mental state assessments during admission and over the subsequent nine months.

Both groups showed a decline in positive symptoms but this was more marked in the CT group (P < 0.001). At 9 months 5% of the CT group, v. 56% of the control group, showed moderate or severe residual symptoms.

CT appears to be a potent adjunct to pharmacotherapy and standard care for acute psychosis. Issues concerning internal and external validity of the study and opportunities for further research are discussed.

Different approaches to estimating local catchment-area needs for psychiatric services are illustrated and compared.

Data from an epidemiological morbidity survey of a random sample of 496 adults were available, as were actual service utilisation rates. Four types of utilisation were modelled (i.e. overall out-patient, in-patient, emergency clinic) using social indicators available from Statistics Canada census-tract data. Finally, a case–control study compared out-patients from a deprived and an affluent catchment area, matched case by case for primary diagnosis, age, sex and residential status (n=52).

Modelling proved highly predictive of utilisation, the overall-use model accounting for 73% of the variance. The case–control study indicated a higher rate of Axis II traits, substance abuse and needs for social care in the deprived catchment area.

Resource allocation based on the social indicators modelling method was more consistent with sensible distribution of human resources. None of the methods, however, appear to reflect adequately the severity of caseloads evidenced in the case–control study.

Refugees have long been considered at risk for mental disorder. We sought to characterise this risk in an out-patient refugee sample by analysing the relationship between psychiatric symptoms and dysfunction, and between symptoms and the socio-demographic background and stressors specific to this refugee sample.

A consecutive sample of 231 refugee patients referred to the psychiatric out-patient unit at the Psychosocial Centre for Refugees, University of Oslo, was examined with a semi-structured interview guide, Brief Psychiatric Rating Scale (BPRS), Hopkins Symptom Check-List (HSCL-25) and a check-list for post-traumatic symptoms (PTSS-10). Global Assessment of Function (GAF) scores were obtained; and the data were analysed using nine predictor variables.

It was found that 46.6% of the patients had a post-traumatic stress disorder according to the criteria for DSM–III–R as the main diagnosis, while the mean GAF score for the patients was 57.3. Analysis of the GAF and BPRS data did not reveal any predictor of psychotic behaviour. However, torture emerged as an important predictor of emotional withdrawal/retardation. Also, age, gender and no employment or education predicted for anxiety/depression, while refugee status and no employment or school predicted for hostility/aggression.

The results confirm earlier findings that refugees constitute a population at risk for mental disorder. Past traumatic stressors and current existence in exile constitute independent risk factors. However, stressors other than those discussed here appear to be important also, particularly with regard to psychotic symptoms.