Population ageing and the high costs of care support for elderly people have concentrated attention on economic issues. Is there an association between costs and cognitive disability?

To compare service utilisation and direct costs for elderly people with different degrees of cognitive disability, and between people living in households and in communal establishments.

Secondary analysis of Office of Population Censuses and Surveys (OPCS) Disability Surveys data compared service utilisation and costs for 8736 elderly people with cognitive disability. Cost estimates were constructed for all health and social care services.

A much greater proportion of people at higher levels of cognitive disability lived in communal establishments, where their (direct) costs were much higher than when supported in households. Service utilisation patterns and costs varied with cognitive disability.

It is important to look at the full range of living arrangements and support services when examining costs. The potential cost implications of pharmacotherapies, other treatments or new care arrangements cannot be appreciated without such a broad perspective.

Little evidence exists regarding the effectiveness or cost-effectiveness of alternative treatment services in the field of child and adolescent psychiatry.

To assess the cost-effectiveness of a home-based social work intervention for young people who have deliberately poisoned themselves.

Children aged ⩽16 years, referred to child mental health teams with a diagnosis of deliberate self-poisoning were randomly allocated to either routine care (n=77) or routine care plus the social work intervention (n=85). Clinical and resource-use data were assessed over six months from the date of trial entry.

No significant differences were found between the two groups in terms of the main outcome measures or costs. In a sub-group of children without major depression, suicidal ideation was significantly lower in the intervention group at the six-month follow-up (P=0.01), with no significant differences in cost.

A family-based social work intervention for children and adolescents who have deliberately poisoned themselves is as cost-effective as routine care alone.

Despite the lack of consistent empirical support, modern diagnostic criteria of schizophrenia give particular emphasis to Schneider's first-rank symptoms (FRSs).

To examine the diagnostic significance of FRSs for schizophrenia by trying to overcome the limitations of previous studies.

This study examined the diagnostic accuracy of FRSs for schizophrenia in 660 in-patients with the full spectrum of functional psychotic disorders. Schizophrenia was diagnosed according to three criteria: DSM–III–R broad, DSM–III–R narrow and Feighner, the latter being considered as the gold standard because it does not give particular emphasis to FRSs.

FRSs were highly prevalent in both schizophrenia and non-schizophrenic psychoses. The likelihood ratios (and 95% Cl) of one or more FRSs for Feighner, DSM–III–R narrow and DSM–III–R broad schizophrenia were 1.06 (0.94–1.20), 1.23 (1.09–1.39) and 1.73 (1.44–2.08), respectively. These data indicate that FRSs do not significantly increase the likelihood of having schizophrenia.

FRSs are not useful in differentiating schizophrenia from other psychotic disorders. Diagnostic systems for schizophrenia that are heavily based on these symptoms may arise from a tautological definition of the disorder.

Data from surveys involving 21 724 subjects aged ⩾65 years were analysed using a harmonised depression symptom scale, the EURO–D.

To describe and compare the effects of age, gender and mental status on depressive symptoms across Europe.

We tested for the effects of centre, age, gender and marital status on EURO–D score. Between-centre variance was partitioned according to centre characteristics: region, religion and survey instrument used.

EURO–D scores tended to increase with age, women scored higher than men, and widowed and separated subjects scored higher than others. The EURO–D scale could be reduced into two factors: affective suffering, responsible for the gender difference, and motivation, accounting for the positive association with age.

Large between-centre differences in depression symptoms were not explained by demography or by the depression measure used in the survey. Consistent, small effects of age, gender and marital status were observed across Europe. Depression may be overdiagnosed in older persons because of an increase in lack of motivation that may be affectively neutral, and is possibly related to cognitive decline.

Most research on expressed emotion (EE) has used an empirical approach to describe relatives' ways of coping with people with schizophrenia.

To use the stress and coping model proposed by Lazarus and Folkman to examine how relatives coped with patients.

Patients with DSM–III–R schizophrenia and their relatives were assessed just after hospitalisation of the patients and nine months after discharge. Both assessments included the symptoms of the patients and the coping strategies, burden, distress and levels of EE of the relatives.

Fifty patients and 50 relatives were assessed at inclusion, and 31 patients and 36 relatives at follow-up. Coping strategies were used more frequently at inclusion than at follow-up. Problem-focused coping was the strategy used more often at both assessments. Avoidance coping was strongly associated with burden, distress and high EE at both assessments.

Ways of coping are influenced by relatives' perceptions of the situation with patients. Avoidance strategies seem to be less effective in regulating the distress of care-givers than problem-focused strategies.

Health of the Nation Outcome Scales (HoNOS) have been developed to measure outcomes in people with mental health problems.

The particular physical and cognitive problems affecting older people requires a specific scale for their measurement. We describe the development of such a scale, named HoNOS 65+.

Pilot, validity and reliability studies were carried out on an amended scale. Validity was assessed by comparison with existing scales reflecting depression, cognitive function, psychiatric symptomatology, activities of daily living and functional abilities. Reliability was measured in two centres.

HoNOS 65+ was successfully amended to include specific aspects of mental health problems in older people including the phenomenology of depression, delusions occurring in the presence of dementia, incontinence and agitation/restlessness. HoNOS 65+ was able to discriminate between people suffering from organic and functional illnesses. Correlations with other scales indicated reasonable validity. Reliability was satisfactory.

Aversion of HoNOS 65+ is presented (see pp. 435–438, this issue) which is appropriate for use in elderly people with mental health problems.

Hospital-based studies suggest that depression in old age relates to organic brain changes.

To determine whether these findings are confirmed in a population-based sample.

A population sample of non-demented 85-year-olds (227 mentally healthy and 62 with DSM–III–R depression were given a neuropsychiatric examination and computerised tomographic scans of the brain, and followed for three years.

On the Mini-Mental State Examination, those with a low educational level with major depression performed worse than the mentally healthy; this distinction was not evident among those who had received higher education. Measures of brain atrophy were similar in depressed and mentally healthy individuals. The three-year incidence of dementia was increased in those with early-onset major depression.

Higher education may protect against cognitive symptoms in depressed individuals. The association between depression and cerebral atrophy in the elderly is not very strong. The higher incidence of dementia in those with early-onset major depression may be due to a longer lifetime duration of depression, emphasising the importance of detecting and treating depression in the community.

The Edinburgh High-Risk Study is designed to explore the underlying pathogenesis of schizophrenia.

To establish the sample characteristics of the first 100 subjects in this study of young adults at risk of schizophrenia for genetic reasons, and to compare them with appropriate controls.

Details of the recruitment of the first 100 high-risk subjects aged 16–25 years into a prospective Scotland-wide study are given. Subjects and 30 age- and gender-matched normal controls were interviewed using the PSE, SADS-L and SIS and an unstructured psychiatric interview.

Some significant differences emerged between the high-risk group and the control group, namely in previous psychiatric history (31 v. 6.3%), forensic contacts (19 v. 3.1%) and delinquent behaviour (20 v. 3.1%). There were also differences in some parameters from the SIS: childhood social isolation, interpersonal sensitivity, social isolation, suicidal ideation, restricted affect, oddness and disordered speech.

These differences may represent increased risk of developing schizophrenia although their true significance will not be revealed until the cohort has been followed through the at-risk years.

There is growing concern about patient satisfaction with psychiatric in-patient provision. This paper measures satisfaction in psychiatric in-patients and its relationships with patient characteristics and ward experiences.

To: (a) measure overall in-patient satisfaction; (b) examine its relationship to in-patient experiences; and (c) examine its relationship to patient factors.

Four hundred and thirty-three patients were interviewed. Satisfaction was assessed by a single question, the Client Satisfaction Questionnaire (CSQ) and by a semi-structured interview.

Over three-quarters of the patients were satisfied, but two-thirds reported adverse events. Females, younger patients and those detained were more dissatisfied. No significant relationship was found for ethnic group. Results were similar in the mental hospital and district general hospital.

There remain problems with satisfaction scales. Qualitative approaches to examine patients' experiences in hospital and the causes of dissatisfaction are recommended.

Homelessness is a major public health problem among persons with severe mental illness (SMI). Cost-effective programmes that address this problem are needed.

To evaluate the cost-effectiveness of an assertive community treatment (ACT) programme for these persons in Baltimore, Maryland.

A total of 152 homeless persons with SMI were randomly allocated to either ACT or usual services. Direct treatment costs and effectiveness, represented by days of stable housing, were assessed.

Compared with usual care, ACT costs were significantly lower for mental health in-patient days and mental health emergency room care, and significantly higher for mental health out-patient visits and treatment for substance misuse. ACT patients spent 31% more days in stable housing than those receiving usual care. ACT and usual services incurred $242 and $415 respectively in direct treatment costs per day of stable housing, an efficiency ratio of 0. 58 in favour of ACT. Patterns of care and costs varied according to race.

ACT provides a cost-effective approach to reducing homelessness among persons with severe and persistent mental illnesses.

Difficulties in family functioning are often evident when an adolescent has anorexia nervosa, and the possible causative or contributory role of such difficulties in the illness is unclear.

To elucidate the relationship between severity of anorexia nervosa and difficulties in family functioning and whether clinical improvement results in diminution of self-rated family difficulties.

Thirty-five adolescents with anorexia nervosa and their mothers completed the Family Assessment Device (FAD) while clinicians administered the McMaster's Structured Interview of Family Functioning (McSIFF). Severity of anorexia nervosa was rated at baseline and at one year follow-up using the Morgan–Russell Schedule.

Clinicians and patients were more critical of the families' functioning than parents. There was an inverse association between the extent of family difficulties and severity of anorexia nervosa. Over time subjects improved clinically but this was not matched by improvement in family functioning.

Difficulties in family functioning do not appear to be directly associated with severity of anorexia nervosa nor do these difficulties reduce with clinical improvement, in the short term.

Most individuals who, shortly after trauma, express symptoms of post-traumatic stress disorder (PTSD) recover within one year of their traumatic experiences. In contrast, those who remain ill for one year rarely recover completely. The early identification of the latter is, therefore, very important.

To prospectively evaluate predictors of PTSD at four months and one year.

We followed 236 trauma survivors recruited from admissions to a general hospital's emergency room for four months, at which point 41 (17.4%) met diagnostic criteria for PTSD. Twenty-three of these individuals, and 39 individuals without PTSD at four months, were assessed again at one year.

Depressive symptoms were the best predictors of PTSD at both time points. Intrusive symptoms and peri-traumatic dissociation were better at predicting four-month PTSD than one-year PTSD.

The occurrence of depression during the months that follow a traumatic event is an important mediator of chronicity in PTSD.

Studies suggest that symptoms of traumatic grief constitute a distinct syndrome worthy of diagnosis.

A consensus conference aimed to develop and test a criteria set for traumatic grief.

The expert panel proposed consensus criteria for traumatic grief. Receiver operator characteristic (ROC) analyses tested the performance of the proposed criteria on 306 widowed respondents at seven months post-loss.

ROC analyses indicated that three of four separation distress symptoms (e.g. yearning, searching, loneliness) had to be endorsed as at least ‘sometimes true’ and four of the final eight traumatic distress symptoms (e.g. numbness, disbelief, distrust, anger, sense of futility about the future) had to be endorsed as at least ‘mostly true’ to yield a sensitivity of 0.93 and a specificity of 0.93 for a diagnosis of traumatic grief.

Preliminary analyses suggest the consensus criteria for traumatic grief have satisfactory operating characteristics, and point to directions for further refinement of the criteria set.

Resources to address the needs of parents of intellectually disabled children in developing countries are limited.

The efficacy of interactive group psychoeducation on measures of parental attitude towards intellectual disability was assessed in southern India.

Fifty-seven parents randomised to 10 weeks of experimental and control therapy were assessed using the Parental Attitude Scale towards the Management of Intellectual Disability. The pre- and post-intervention measurements were done by a single-blinded rater and compared.

The intervention group had a statistically significant increase in the outcome scores and clinical improvement in the total parental attitude score, orientation towards child-rearing, knowledge towards intellectual disability and attitude towards management of intellectual disability, but no change in attitude towards the intellectual disability subscale.

Interactive group psychoeducation is effective for changing the attitude of parents with intellectually disabled children, and is a viable option to be developed in situations where resources are limited.

Reform of mental health legislation for England and Wales is due. MHRTs offer an important check in the balance between patient and public rights.

To study the quantity and outcome of MHRTs in special (high-security) hospitals.

Data were extracted from the records of 1670 patients detained under mental illness or psychopathic disorder classifications in special hospitals during 1992.

There were 661 MHRT hearings, mostly requested by patients. Forty-three (7%) discharges were ordered, often without key data about continuing care in the written evidence. There were 56 recommendations for transfer to lesser security. Correlates of MHRT discharge were: female gender, younger age (in women), a legal classification of psychopathic disorder and shorter length of stay. Conditional discharge did not necessarily mean departure from special hospital.

Special hospital MHRTs result in few changes in patient status. A probable need for improvement in the evidence put before an MHRT was found. Legislation reformers should consider an extension of MHRT powers to order transfer between levels of security.