A recent simulation concluded that the serotonin-specific reuptake inhibitor (SSRI) paroxetine was more cost-effective than the tricyclic antidepressant (TCA) imipramine, despite substantially higher medication acquisition costs.

We replicated the previous model and revised key assumptions which drove the results. The revised model was subjected to sensitivity analysis.

Most scenarios in the revised model showed that the TCA is equally or more cost-effective than the SSRI. Model revision producing these results were changes in assumptions about switched treatment success rates, treatment length and initial treatment success. The revised model appears sensitive to drug acquisition and delivery costs and costs of treatment failure.

Based on the model, a policy of using TCAs as first-choice antidepressant treatment, with SSRIs reserved for those patients not doing well initially, appears more cost-effective than the reverse sequence. Given limitations in current knowledge about key parameters to include in a simulation model, large prospective random-assignment cost-effectiveness studies are needed.

Obsessive–compulsive disorder (OCD) is heterogeneous, with some forms related to Gilles de la Tourette's syndrome (GTS). This is a phenomenological study designed to investigate the nature of these possible OCD subtypes and the relationship between OCD and GTS.

We evaluated 20 adult outpatients with OCD, 21 with GTS, and 20 with OCD plus GTS using a semi-structured interview designed to assess cognitive, sensory and autonomic phenomena preceding repetitive behaviours.

More cognitions and autonomic anxiety and fewer sensory phenomena were reported in OCD than in GTS. Like the GTS group, the OCD plus GTS group reported more sensory phenomena and fewer cognitions than the OCD group.

The presence or absence of cognitions, sensory phenomena, and autonomic anxiety distinguishes repetitive behaviours in patients with OCD from those with OCD plus GTS, and GTS. These subjective experiences may be useful in subtyping OCD and may represent valid predictors of prognosis and treatment response.

Schizophrenia may in some cases be a neurodevelopmental disorder. Breast milk is important to the developing brain. Might a lack of breast milk be an environmental risk factor in schizophrenia?

Mothers of 45 schizophrenic patients in Nithsdale, southwest Scotland, completed a questionnaire about whether or not their offspring had been breast-fed.

The incidence of breast-feeding in patients was 29% and in sibs 38%. Most patients were born in the 1940s and 1950s. The incidence in patients born in these two decades, 33 and 26%, respectively, was significantly lower than in Scottish surveys in 1946 (81%) and 1958 (51%). Those patients who had not been breast-fed had more schizoid and schizotypal personality traits in childhood and a poorer social adjustment than their sibs; breast-fed patients did not differ from their sibs.

Fewer schizophrenic patients than normal were breast-fed. Lack of breast milk may be a risk factor in the neurodevelopmental form of schizophrenia.

Full recovery rates in naturalistic studies of the treatment of elderly depressives are invariably lower than in clinical trials. This may be the result of inadequate treatment due to the lack of clear treatment strategy recommendations for the elderly.

This is a naturalistic prospective study of depressed elderly in-patients in three Dutch psychiatric hospitals. Patients were included when they suffered from any mood disorder according to DSM - III - R criteria. Severity of the depression was measured on the Montgomery -Asberg Rating Scale.

Antidepressants were prescribed to more than 90% of the patients. More than half of them received only one treatment. The dose of the antidepressants was less than the recommended dose for adults in 55% of cases. Full recovery from the depressive episode was achieved in less than half of the patients (33–45%).

In the present study a relatively poor outcome of the antidepressant treatment of elderly depressives has been found. A combination of low treatment expectations and fear of vigorous treatment seems to have been important.

Exemplified by a randomised trial on antimanic treatment, this paper addresses the question of whether selection of patients for drug trials may limit the applicability of study results from the randomised patients to a wider population.

During two-year period, all consecutively admitted patients from a defined catchment area were screened for inclusion criteria concerning age, diagnosis and severity of illness. The subsequently excluded subgroups of patients were compared with the randomised patients by multivariate data analysis.

One hundred and sixty-four patients met the inclusion criteria. However, after exclusion for various reasons, only 27 (17%) patients remained for randomisation. The randomised patients and the excluded patients differed substantially.

The generalisability of trial results is limited. Reports of randomised drug trials should carefully describe the screening procedure for inclusion and, when possible, present relevant comparisons-between the randomised patients and the various subgroups of excluded patients.

Models of sex therapy for sexual dysfunction in single men are available, but their value is not well established. This controlled study compared three approaches to the treatment of sexually dysfunctional single men.

Sixty-nine single men diagnosed as sexually dysfunctional were randomly assigned to treatments focusing on either their sexual dysfunction, their interpersonal problems, a combination of both or a waiting list; 51 completed treatment and 50 the one-year follow-up. Treatment was administered in small groups in 15 weekly sessions and four six-weekly sessions during the first six months of a year-long follow-up.

No clinically meaningful change was observed during the waiting period. In contrast, a significant and equivalent improvement was observed in all treatment groups by the end of treatment. However, differences between them were in evidence at 6 and 12 months' follow-up.

Both treatments paying attention to the patients' interpersonal difficulties resulted in significantly better outcomes overall than the approach that concentrated on problems in sexual functioning alone.

Predictive genetic testing for Huntington's disease has been available in Cardiff since 1987 using linked genetic markers, and since 1993 using direct mutation testing, which can also be used as a diagnostic test. During this period there have been numerous referrals that have required liaison with psychiatric services at all stages of the testing programme.

A series of cases was selected to highlight issues from both genetic prediction and diagnosis that are relevant to psychiatric practice and have arisen during the testing programme.

Issues have been raised concerning competence to consent to testing in the context of psychotic illness; depression and suicidal ideation in test candidates; requests for testing from third parties such as psychiatrists, social services and the courts; and testing of children.

As genetic testing becomes possible for more disorders the lessons learned from Huntington's disease will provide valuable guidelines for counselling.

Little is known about the long-term mortality and causes of death after first psychiatric admission.

A consecutive series of 87 patients admitted for the first time from a strictly defined catchment area to Saxondale Hospital, Nottinghamshire, who were discharged in 1974 and 1975, were traced in 1992 to either their general practitioner or death. The causes of their deaths were ascertained and the observed mortality was compared with expected mortality.

Twelve subjects had died. None had committed suicide, and there were no open verdicts or accidental deaths. Although the observed mortality was higher than expected, there was no significant excess.

There may be little scope for reducing suicide rates by targeting patients for careful follow-up after discharge from their first psychiatric admission. More research is required before large investments are made in potentially fruitless interventions to achieve the objectives of The Health of the Nation.

The main objectives of the survey were: (a) to analyse the sociological, clinical and illness-related correlates of mental illness in primary care; (b) to study, during one-year follow-up, outcome and use of health resources.

The survey comprised a two-phase cross-sectional study. In the first phase patients were classified using the GHQ-28 or by the general practitioner (GP). In the second phase they were assessed by the SCAN system.

The prevalence rate of mental illness (in attenders) using the GHQ was 33.2%. The corresponding rate for the GP was 14.1%, and for the SCAN 31.5%. Mental illness mainly comprised depression, anxiety and alcohol-related diagnoses. The presence of mental illness and the use of health resources during follow-up were dependent on demographic characteristics and on their original psychiatric status.

In primary care, mental illness constitutes a major health problem. Despite this fact. GPs do not recognise a substantial proportion of these health problems.

The relationships between personality disorders and suicide were investigated among two aboriginal groups and the Han Chinese in East Taiwan.

Biographical reconstructive interviews were conducted for consecutive suicides from each of the three ethnic groups (116 suicides in total), 113 of whom were matched with two controls for age, gender, and area of residence.

In all three groups, a high proportion of suicides suffered from ICD-10 personality disorder before suicide (46.7–76.7%), and the most prevalent category was emotionally unstable personality disorder (F60.3) (26.7–56.7%). The risk for suicide was mainly significantly associated with F60.3, comorbidity among personality disorders, and comorbidity of personality disorder with other psychiatric disorders, particularly severe depression.

The main category of personality disorder significantly associated with the risk of suicide is F60.3 in ICD-10. The risk is highest for a comorbidity of this category and severe depression.

The aim of this study was to determine the effect of physical morbidity on the outcome of patients with psychiatric disorder, and to compare the effects of non-medically and medically explained symptoms.

One hundred and fifty psychiatric cases were recruited using a two-stage design from 1620 consecutive patients attending their GP. Subjects were assessed at the time of screening, and one year subsequently, using the Composite International Diagnostic Instrument adapted for use in primary care (CIDI - PHC) and the Groningen Social Disability Schedule (GSDS). Assessments of psychiatric morbidity were also obtained from GPs.

Medically explained somatic symptoms were strongly related to psychological outcome one year later. Whereas just over a half of patients with no medically explained symptoms had recovered from a psychiatric disorder, the percentage recovery fell to 41% in those with 1 −4 medically explained symptoms, and only 21% in patients with five or more medically explained symptoms.

Physical ill-health has been shown to make an independent contribution to psychological outcome. The specific needs of these patients should receive greater attention.

Research suggests an association between frontal and temporal injury and antisocial conduct. We studied the frequency of antisocial behaviours in fronto-temporal dementia (FTD) where pathology is anterior frontal-temporal, compared with Alzheimer's disease (AD) where pathology is primarily posterior temporal-parietal.

The presence of antisocial conduct was compared in 22 FTD versus 22 AD subjects. All FTD patients had anterior frontal or temporal hypoperfusion with single photon emission computed tomography, whereas those with AD had posterior temporal-parietal hypoperfusion.

Ten FTD and one AD subject showed antisocial behaviours, which included assault, indecent exposure, shoplifting and hit-and-run driving. Three FTD subjects were arrested. This difference was highly significant (P = 0.004).

Degeneration of frontal and temporal lobes predisposes to antisocial behaviour. This study supports a relationship between frontal-temporal dysfunction and certain types of antisocial activities.

The purpose of this study was to examine the effect of treatment on the long-term course of geriatric depression.

Eighty-four elderly patients who had responded to treatment of the index episode of major depression were maintained on full-dose antidepressant medication and followed on a monthly basis for two years. Relapse and recurrence were treated in a systematic manner.

The cumulative probability of surviving for two years without relapse or recurrence was 74%. Of the 14 patients who suffered recurrence following recovery from the index episode, all responded to a change of treatment, and 71% remained well for the remainder of the study. The risk of recurrence was significantly increased by a delayed response to treatment of the index episode.

Continuation and maintenance treatment with full-dose antidepressant medication, frequent follow-up, and vigorous treatment of relapses and recurrences, were associated with a good outcome in this group of elderly patients.

Case management has become the statutory basis of community care in the UK for people with long-term mental disorders, although a randomised controlled trial found no important improvements over standard care. Here we compare the costs and cost consequences of this intervention with standard care.

Resource-use data were collected over a six-month baseline period and for 14 months after randomisation on all patients in the trial.

At 14 months the ratio of control group to treatment group weekly costs was 1.09 (95% CI 0.86–1.38) for total costs; 1.12 (0.76–1.65) for state benefits, and 1.21 (0.61–2.42) for health care costs. Costs were thus lower in the treatment group, but these differences were not significant.

Retrospective power calculations indicated that the trial could have detected differences of 30% in total cost, but would have required 700 patients per arm to detect a 20% difference in health care costs. Hence this study, which had adequate power to detect clinically meaningful differences, was found to be far too small to detect large differences in costs. Funding agencies increasingly request that clinical trials include economic alongside clinical end-points: these findings may have important lessons for that policy.

There have been very few controlled studies of antidepressants in dysthymia, particularly in samples diagnosed reliably and with an adequate length of follow-up. In this investigation, we measured the long-term outcome in a large group of patients meeting DSM – III -R criteria for dysthymia. This study was designed to investigate whether fluoxetine is effective in the treatment of dysthymia.

This randomised study, including 140 patients, compared fluoxetine (91 patients) and placebo (49 patients) on a double-blind basis in two distinct phases: a short-term end-point (3 months with 20 mg/day fluoxetine) and a medium-term end-point (6 months) where the initial responders continued double-blind treatment unchanged and non-responders received an additional treatment of 20 mg/day fluoxetine.

After three months of treatment, response was seen more frequently in the fluoxetine group (42/72) than in the placebo group (14/39, P <0.0001). Improved patients at 3 months were still improved at 6 months. Furthermore, 50% of the non-responders at 3 months improved and rated as responders at 6 months, after fluoxetine was increased to 40 mg daily.

This study showed the significant and persistent action of fluoxetine on dysthymia. The finding that 50% of the non-responders at 3 months were improved at 6 months, after fluoxetine dosage was increased to 40 mg daily, argues in favour of treating dysthymic patients for at least 6 months, and with a higher dosage if the initial doses are ineffective.

Research into the mental health of refugees has burgeoned in recent times, but there is a dearth of studies focusing specifically on the factors associated with psychiatric distress in asylum-seekers who have not been accorded residency status.

Forty consecutive asylum-seekers attending a community resource centre in Sydney, Australia, were interviewed using structured instruments and questionnaires.

Anxiety scores were associated with female gender, poverty, and conflict with immigration officials, while loneliness and boredom were linked with both anxiety and depression. Thirty subjects (79%) had experienced atraumatic event such as witnessing killings, being assaulted, or suffering torture and captivity, and 14 subjects (37%) met full criteria for PTSD. A diagnosis of PTSD was associated with greater exposure to pre-migration trauma, delays in processing refugee applications, difficulties in dealing with immigration officials, obstacles to employment, racial discrimination, and loneliness and boredom.

Although based on correlational data derived from a convenient'sample, our findings raise the possibility that current procedures for dealing with asylum-seekers may contribute to high levels of stress and psychiatric symptoms in those who have been previously traumatised.

Despite the growth in patient satisfaction studies, scant attention has been paid to the satisfaction of patients with a first episode of psychotic illness soon after presentation to services. We were particularly interested in any ethnic differences in satisfaction at this seminal stage in patient care.

Using multi-item questionnaire, face-to-face interviews were conducted with patients and relatives 12 months after first contact with psychiatric services. Relatives were also questioned on support and advice issues related to after-care.

Most patients and relatives were generally satisfied with the treatment, and with the ‘humane’ qualities of psychiatric staff, but were less satisfied with the ‘hotel’ aspects of hospital care. Patients, and particularly relatives, were most concerned about levels of information and advice received. Relatives were dissatisfied with after-care. There were no significant differences between Black and other patients, but some differences between their relatives. Patients born abroad were significantly more satisfied than those born in Britain, irrespective of ethnicity. Compulsory detention under the Mental Health Act was also significant in determining low satisfaction for patients and especially for their relatives.

For improved care in the community patients and their relatives need to be seen as partners in care rather than as passive recipients. The issue of information-giving by psychiatric services demands serious attention. Black patients and their relatives were not especially likely to be dissatisfied.