In Victoria, Australia, systematic assessment of outcomes in mental health services are being instituted.

To carry out a large-scale field trial of the Health of the Nation Outcome Scales (HoNOS).

2137 clients were rated by mental health workers on the HoNOS, and about half were rated again within a few months.

While interrater reliability of the total score was satisfactory, that of some individual items was unacceptable. Significant associations with age and gender were found, and clients with non-psychotic disorders obtained higher (i.e. worse) ratings than those with psychotic disorders. There were relationships between service use and HoNOS total score. For the group as a whole, total scores had not changed at the second rating, but admissions and discharges were associated with increases and decreases in total score. Among clients in the community, there was no relationship between change in HoNOS total score and frequency of contacts.

Certain items, notably 11 and 12, were unreliable. The absence of evidence of sensitivity to change may be due to the short re-rating interval, little real change in the clients, or the characteristics of the scale itself.

Hyperkinetic disorder or attention-deficit hyperactivity disorder (ADHD) is an important clinical condition.

The research evidence for a genetic contribution to ADHD is reviewed.

Measurement of the phenotype, the extent to which attention deficit and hyperactivity are heritable and molecular genetic findings are discussed. Future research directions are also considered.

ADHD is a familial disorder. Available adoption evidence suggests genetic influences are important. Twin studies have primarily focused on trait measures which have consistently been found to be highly heritable. Molecular genetic studies of clinical disorder so far have suggested the involvement of the dopamine DRD-4 receptor gene and dopamine transporter gene (DATI). However, these findings await further replication.

Advances in psychiatric genetics and current research interest in the genetics of ADHD should improve our understanding of aetiological factors and have an impact on treatment.

In spite of intensive research, no causal anatomical lesion has been found in schizophrenia. It may instead be caused by malfunctioning circuits in the corollary discharge, feed forward (CD–FF) systems of thought.

To integrate with the CD–FF hypothesis recent data showing that subcortical motor systems participate in thinking.

We review CD–FF concepts in relation to recent evidence that ‘motor’ brain structures participate in cognitive processing.

Malfunctioning of CD–FF systems that integrate thinking and consciousness could produce auditory hallucinations, delusions and disorganised thought.

We hypothesise that the pathophysiology of schizophrenia lies in integrative circuits of basal ganglia, thalamus and frontal cortex. Fruitful research directions would include elucidation of CD–FF circuits at even higher brain levels, the behaviour of these circuits during dreaming, and their responses to late maturational events including synaptic elimination.

The Health of the Nation Outcome Scales (HoNOS) were developed to assess the outcome of severe mental disorders in relation to the Health of the Nation Strategy for England.

To validate the HoNOS.

One hundred and fifteen patients were assessed by key workers using HoNOS, and by research workers using SCAN, SBS, and SRPS, and completing HoNOS in the light of this additional material. These assessments were repeated after 6 weeks.

The performance of HoNOS in the hands of key workers was generally poor, in relation both to the research workers' rating of HoNOS and to the criterion instruments. Performance was particularly poor when the change in scores was used as a measure of outcome.

There are serious problems in using HoNOS as a routine measure of clinical status in busy psychiatric services. Its performance is probably related to the training and experience of key workers. Sequential ratings are not a good method for assessing outcome. Managers and planners should be cautious in adopting HoNOS, but it is worthy of consideration in developing a suite of locally agreed outcome measures.

Tragic and high-profile killings by people with mental illness have been used to suggest that the community care model for mental health services has failed.

To consider whether such homicides have become more frequent as psychiatric services have changed.

Data were extracted from Home Office-generated criminal statistics for England and Wales between 1957 and 1995 and subjected to trends analysis.

There was little fluctuation in numbers of people with a mental illness committing criminal homicide over the 38 years studied, and a 3% annual decline in their contribution to the official statistics.

There are many reasons for improving the resources and quality of care for people with a mental disorder, but there is no evidence that it is anything but stigmatising to claim that their living in the community is a dangerous experiment that should be reversed. There appears to be some case for specially focused improvement of services for people with a personality disorder and/or substance misuse.

Subthreshold conditions (i. e. not meeting full diagnostic criteria for mental disorders in DSM–IV or ICD–10) are prevalent and associated with significant costs and disability. Observed more in primary care and community populations than in speciality settings, varying conceptualisations have been applied to define these conditions.

To examine definitional issues for subthreshold forms of depression (e. g. minor depression) and to suggest future directions for research and nosology in psychiatry and primary care.

A Medline search was conducted. The relevant articles were reviewed with regard to specific categories of information.

Studies applied a myriad of names and definitions for subthreshold depression with varying duration, symptom thresholds and exclusions. Prevalence rates also vary depending upon the definitions, settings and populations researched.

Future research needs to apply methodological and intellectual rigour and systematically consider a broader clinical and nosological context. In addition, collaboration between psychiatry and primary care on research and clinical issues is needed.

Health of the Nation Outcome Scales (HoNOS) were incorporated in a data set recording the routine clinical activities of a mental health team in Liverpool.

To evaluate the use of HoNOS in general adult psychiatry.

All consecutive patients who came in contact with the mental health team were administered HoNOS by the consultant psychiatrist. A cohort (n=204) of patients was identified over a period of 8 months. All patients (n=156) who had a repeat HoNOS after an interval of 6 months were included in the study.

There was an overall reduction in HoNOS scores after an interval of 6 months, more so among patients with psychotic and affective disorders. Patients scoring on other disorders showed no change on HoNOS. The measured change in clinical state based on the Clinical Global Impression scale was broadly consistent with HoNOS scores.

It was feasible to administer HoNOS during routine assessments, but HoNOS data were of limited value in care-planning in day-today clinical practice. The widespread adoption of HoNOS for use in routine clinical practice would be premature.

Antidepressant drugs are usually prescribed at low doses, possibly to avoid adverse reactions. No comprehensive review has addressed the issue of dose, clinical response and tolerability in a quantitative way.

To determine whether high doses of antidepressants are more effective than lowdoses, and how safety is affected by dose.

Trials comparing two or more doses of the same antidepressant were located, and all antidepressants administered were converted to the equivalent dose of imipramine. Generalised estimating equations were used to analyse percentage improvement and adverse event rate according to dose level.

Thirty-three studies were identified. The dose level 100-200 mg imipramine equivalents showed an average improvement of 53% by ‘intention-to-treat’. Higher doses were not accompanied by increased efficacy, while lower doses showed reduction in efficacy. Adverse events significantly increased with dose.

With a low dose of antidepressants, clinicians trade off a slightly reduced chance of improvement for a higher chance of avoiding adverse reactions.

There is evidence that exposure to social and family disadvantages in childhood are a risk factor for adult depression.

To explore the effects of multiple adversity in early childhood on adult depression, and the relative effects of the different adversities.

This study utilises data from the Newcastle Thousand Family Study. Information on childhood disadvantages was collected when the participants were 5 years old, and information on mental health was gathered when they were 33 years old. Mental health data were scrutinised blind to the evidence of early disadvantage, and best-estimate diagnoses of major depressive disorder were made according to DSM–III–R criteria.

Multiple family disadvantages in childhood substantially increase the risk of suffering a major depressive disorder in adulthood. Such disadvantages include family or marital relationship instability, a combination of poor mothering and poor physical care, and a combination of dependence on social welfare and overcrowding. For females major depression was linked in particular to the quality of parenting in early life.

Social and family (especially multiple family) disadvantages during childhood predispose individuals to an increased risk of major depression in adulthood.

In the treatment of panic disorder with agoraphobia, the efficacy of pharmacological, psychological and combined treatments has been established. Unanswered questions concern the relative efficacy of such treatments.

To demonstrate that moclobemide and cognitive–behavioural therapy (CBT) are effective singly and more effective in combination.

Fifty-five patients were randomly assigned to an eight-week treatment of: moclobemide plus CBT; moclobemide plus clinical management (‘psychological placebo’); placebo plus CBT; or placebo plus clinical management.

Comparisons between treatments revealed strong effects for CBT. Moclobemide with clinical management was not superior to placebo. The combination of moclobemide with CBT did not yield significantly better short-term results than CBT with placebo. The CBT results remained stable during a six-month follow-up, although a substantial proportion of patients treated with placebo plus CBT needed additional treatment.

CBT was highly effective in the treatment of panic disorder with agoraphobia and reduced agoraphobia to levels that were comparable to those of non-clinical controls.

The effectiveness of antipsychotic monotherapy in schizoaffective disorder is limited, and further constrained by safety concerns.

We aimed to compare the efficacy, tolerability and safety profile of the new pharmaceutical, olanzapine, with haloperidol.

Data were assessed from 300 DSM – III – R schizoaffective subjects from a larger double-blind prospective international study. Subjects were randomly allocated to six weeks of olanzapine (5–20 mg) or haloperidol (5–20 mg) treatment; responders were followed for up to one year of double-blind, long-term maintenance therapy.

Olanzapine-treated patients achieved a statistically significant greater improvement than haloperidol-treated patients on overall measures of efficacy, including clinical response. Significantly fewer olanzapine patients left the study early, and fewer adverse events were observed among those receiving olanzapine. During maintenance, olanzapine-treated patients continued to experience additional improvement, with fewer EPS but more weight gain than those on haloperidol.

Olanzapine demonstrated substantial advantages over the conventional antipsychotic haloperidol in the management of schizoaffective disorder.

Persistent drug-resistant psychotic symptoms are a pervasive problem in the treatment of schizophrenia.

To evaluate the durability of the treatment effects of cognitive–behavioural therapy for chronic schizophrenia one year after treatment termination.

A comparison of clinical outcomes was made at one-year follow-up from a randomised trial of cognitive–behavioural therapy, supportive counselling and routine care alone in the treatment of chronic schizophrenia.

Seventy out of the 72 patients (97%) who completed treatment were assessed at follow-up. There were significant differences between the three groups when positive and negative symptoms were analysed by means of ANCOVAs. Between-group comparisons indicated significant differences between cognitive–behavioural therapy and routine care at follow-up for positive symptoms. There was a trend towards significance for both cognitive–behavioural therapy and supportive counselling to be superior to routine care alone on negative symptoms.

At 12-month follow-up the significant advantage of cognitive– behavioural therapy compared to routine care alone remained.