Psychiatry has been, among medical disciplines, the one showing the highest conflict between a «positivist» model and the «hermeneutic» tradition. In particular, in recent years several authors have suggested that both the scientific method and a scientific mentality should be introduced in psychiatric practice and research. They claim that criteria like a strong correlation among clearly defined signs and symptoms, a high predictive value towards the outcome and therapeutical response, and a clearly defined relationship between the symptoms and etiology are necessary to accept a diagnositc entity. Since in the case of e.g. schizofrenia such requirements are not met, some authors even suggest that the concept of schizofrenia should be abandoned. The present paper aims to show that such problems are not unique to mental disease, but are common to several branches of medicine. For example, the definition and classification of cancer follow a «polythetic» criterion which is similar to the concept of «family resemblances». Also, diagnostic reproducibility is often low in other medical disciplines. The paper examines how such methodological problems could be dealt with using the tools of epidemiology.

Objective - To survey and analyse the extent of utilization of «Non Pharmacological Interventions» (NPI) in the public mental health services of a large city. Setting - Inteview of the entire medical staff employed in 1991 in 10 Departments of Mental Health in the urban area of Naples, Italy. Main measures - A «ad hoc» questionnaire was prepared to gather informations on prevalence of use on NPI in different therapeutic settings, the selected technique according to the different diagnostic categories and the degree of professional training of the interviewed medical personnel. Result - The NPI, as the only treatment, was preferred by the large majority (86%) of the medical staff. The patients treated with NPI was double in outpatient than in inpatient. Although the medical staff did not use the same diagnostic criteria (ICD-9, DSM-III, others) anxiety (49%) and personality disorders (14,3%) were the diagnostic categories most commonly selected for NPI. At the time of the survey 24% of the patients were treated with psychotherapy. Support psychoterapy, psychoanalysis, family therapy were the most frequently employed. The support psychotherapy was mainly used in treatment of schizophrenia. Near to 50% of the medical staff reported a combined use of up to five different NPI. By and large choice of NPI was found dependent on the type of training and inversly correlated with the degree of seniority. Conclusions - The data obteined from the present survey show the large use and variability in NPI employed in public mental health services. The analysis of psycotherapy used suggests a different approach between public and private sector.

Objective – The paper discusses conceptual, methodological and clinical issues of comorbidity from the perspective of more recent epidemiological studies. Further the potential causal and pathogenic role of temporally primary disorders for the onset of secondary disorders is evaluated. Results – The available data suggest so far that comorbidity (a) is not an artefact of assessment strategies, sampling or design features, (b) is specific in different disorders, (c) is particularly frequent in anxiety and affective disorders, (d) affects systematically the course of the comorbid conditions and (0 might be related to symptom progression models. Conclusions – Furthermore, evidence is presented that specific forms of primary anxiety disorders affect the risk for secondary depressive disorders, increase the likelihood of non-remission as well as the number of subsequent depressive episodes.

Objective - To set out the author's views of the role of epidemiology in social psychiatry and to illustrate this role with reference to affective disorders. Method - Review of work carried out in two areas; the bearing of gender and of age on rates of affective disorder. Results - The use of sociodemographic categories to define high risk groups suggests that affective disorder may be related strongly to role satisfaction and that age may have a pathoplastic effect on the form of disorder that overrides all but the strongest social influences. Conclusions - Epidemiology is an essential tool of the social psychiatrist, but its main strength is in clarifying the nature of the questions to be asked and suggesting new lines of investigation.

Objective – Epidemiological principles underpin much medical research particularly that concerned with the planning and evaluation of health services, including research in community and social psychiatry. The aim of this paper is to review some of the common uses of epidemiology in community psychiatric research and to discuss some methodological issues that arise frequently in epidemiological research in community settings. Methods – This is a review of the relevant literature and of the work currently in progress in the department of psychological medicine of the university of Wales College of Medicine. Results – Among the many uses of epidemiology in health care, four are especially relevant in community psychiatric settings: the assessment of the mental health needs of the population (four approaches are described: the collection of routine data, surveys of existing patients, surveys of the general population and statistical modelling), the identification of risk factors of disease, the contribution to prevention and the assessment of the clinical effectiveness of health care interventions. The most important methodological issues include causal inference which in epidemiology takes the form of explaining the association between an exposure and disease (chance, bias, confounding, reverse causality and causality), the issue of confounding and how to adjust for it and issues arising in the context of specific study designs. Conclusion – Epidemiology has become a set of methods used to investigate a wide range of clinical questions. Population based research is an essential part of clinical research but epidemiological knowledge is also needed by clinicians in order to critically appraise and interpret the scientific literature.

Objective — This article reviews the extent to which epidemiology and disability measurement can con-tribute to mental health and service policy and planning. Methods — The review explores the information required for local, mental and international policy and planning in a variey of settings. Results — Epidemiology and disability measurement are essential to underpin policy and planning that are responsive to local needs, together with information on service inputs and processes and health outcomes. Conclusions — Epidemiology and disability measurement should be an integral part of the policy and planning process to support the development of service, and service processes and the measurement of health outcomes for not only specialist mental heath services, but also activities in primary care, schools and workplaces.

Objectives - To present a comprehensive review of the studies assessing the frequency of PTSD in the general population, in clinical populations and among subjects at risk. Design - An extensive search was made using the Excerpta Medica Psychiatry CD-ROM 1980-1993 (October). Using post-traumatic stress disorder as a key word, a total of 1,057 papers published in this timespan were retrieved. A further search was made using the same key word with MEDLINE CD-ROM 1988-1993. A manual search was also performed for all issues of the Journal of Traumatic Stress. Results - A total of 135 studies meeting inclusion criteria were selected for this review. Almost two thirds (n = 86, 64%) of these studies were carried out in the United States; only 8 (6%) studies have been carried out in developed countries. The sample size ranges from a low of 11 subjects up to a high of 22,463 subjects. The mean sample size is 500 and the median is 108. In terms of assessment methods, in one third (n = 45, 33%) of the studies the investigators used a PTSD symptom checklist (either self- administered or administered by a clinician), based on DSM criteria, to generate a PTSD diagnosis. In more than in one third of the studies (n = 44, 33%) of the studies, a structured interview was administered (e.g., the DIS, the SCID, the SADS), while in the remaining surveys the diagnostic evaluation was based either on an un- structured clinical assessment or on the administration of other specific assessment instruments (e.g., M-PTSD, IES, SCL-90-R or others). In 77 studies (57%) the investigators based their assessment on DSM-III diagnostic criteria for PTSD, whereas in 55 studies (41 %) DSM-III-R criteria were employed. Prevalence rates are discussed separately for the different population groups. Conclusions - There has been a remarkable increase in the number and quality of epidemiological studies on PTSD over the past decade. A substantial amount of information is now available about the frequency of PTSD among different population groups and among at risk subjects, and about risk factors, common symptom patterns, and natural history of this disorder. However, a number of important limitations of these studies are to be noted and should be addressed by future research efforts.

Objective — To discuss the contribution of epidemiology and epidemiological methods to psychosomatic medicine. Method — Critical review of the literature, including both philosophical concepts and empirical data. Results — The adjective «psychosomatic» has been used in two different ways: in the so called «psychosomatic» or holistic approach to medicine; and in a narrower approach, referring to particular disorders in which psychological factors were considered to have a fundamental aetiological role. While the ideal of the holistic, «humanistic» or «anthropological» approach should probably be never abandoned, the practical limitations of encompassing models, including Engel's bio-psycho-social model are also obvious: they may be heuristically sterile. On the other side, in relation to the narrow psychosomatic approach, psychogenetic views in the so called «psychosomatic illnesses» have been strongly criticized on empirical grounds. The potential of epidemiological methods to study these illnesses, but also «somatopsychic» disorders is shown in a number of papers in the empirical literature. We have grouped such contributions, including our own experience, in the five categories suggested by M. Shepherd for epidemiological methods in general: 1) the completion of the spectrum of disease; 2) the establishment of outcome; 3) the actuarial assessment of morbid risk; 4) the evaluation of the efficacy of treatment; and 5) the conceptual construction of diagnosis and classification. Conclusions — The contribution of epidemiological data to areas of interest in psychosomatic medicine has been relevant in recent years. The potential of epidemiological methods in this area is very important both to increase knowledge and to improve the quality of clinical practice.

Objective – The aim of the present study is to provide an epidemiological study about suicide in Verbano-CusioOssola province, between January 1990 and December 2000. Design – The present study is based on the acquisition of data through the examination of model 45, that registers all the cases of violent death and suicide, filed in Verbania Republic Procuration. Setting – The Verbano-Cusio-Ossola province extends 2,255 Km2 and counts 161,248 inhabitants. The Procuration in Verbania has territorial jurisdiction on the whole province of our study. Main outcome measures – The data obtained were presented in terms of descriptive analysis, evaluation of standardised rates of the province of Verbano-Cusio-Ossola. In order to appreciate the differences in comparison with the mean rates of northern Italy, Standardised Mortality Rates (SMRs) with the confidential intervals (IC 95%) have been used. Results – In the eleven years period considered, 297 cases of suicide were notified at the Court with a rate of 16.74 per 100,000 inhabitants. The trend of suicide in the period examined is heterogeneous with significant differences between males and females. The analysis of SMRs points out that the incidence of suicide is higher in the province of VCO than in Italy in the same decade and that this difference is mostly due to an higher rate of suicide among women. The analysis of social-demographic parameters of the examined population confirms the data from international literature: suicide is more present in elderly, in widowers and in the retired. Conclusions – The present study means to provide a description of the suicide phenomenon, in a specific geographical and cultural context, in order to point out the problematic sides in a diagnostic-clinical point of view that may be an incentive to a larger preventive care.

Aim – To describe the rationale for introducing molecular genetic analyses to psychiatric epidemiology. This offers new possibilities for aetiological research on common mental disorders. Method – In addition to the traditional variables used in field surveys, it is now possible to include molecular genetic information. This is currently done by looking for allelic associations rather than by linkage analysis, and can be directed either at traits conferring susceptibility or at states. The purpose is to identify quantitative trait loci (QTLs) by examining candidate genes. An alternative strategy is genome scanning, which can identify genes by their chromosomal position with increasing resolution. Results – Some associations have already been reported in the literature, linking personality traits with particular alleles: extraversion or novelty-seeking with a polymorphism of the dopamine DRD4 receptor gene; and neuroticism with a polymorphism of the serotonin transporter gene. Conclusions – These findings are of major interest, but cannot yet be looked upon as confirmed. What is significant for epidemiology is the opportunity to link behavioural and psychiatric variables with genes influencing biochemical and physiological processes in the brain, and to do so at the population level. For further allelic association studies, there are four principal requirements: valid measures of phenotypes; replication of findings across diverse populations; more candidate genes; and exploration of the interaction between genotype and environmental exposures from conception to late life. Through such research, psychiatric epidemiology can now investigate biopsychosocial phenomena.

Objective - To try and specify questions of special relevance for suicidological research. Methods - Discussing the merits of questions pertaining to epidemiology and various theories on suicidal behaviour. Results - Four types of questions are defined: How many persons show suicidal behaviour? Who are they? Why do they do it? and What can we do about it? Answers to the first three questions are required when approaching question four: What can we do about it? Conclusion - The complex patterns and backgrounds of suicidal behaviour call for interdisciplinarity and for an increase in both multifactorial and process-related approaches as well as practicable, evidence-based and feasible intervention efforts.

Scope – This overview analyses findings coming from researches that considered the interaction between depression and Alzheimer's disease (AD). Method – Information was collected from the Medline database and from a reasoned manual analysis of the published studies. Results – The prevalence of depressive symptoms in patients with AD is elevated (40-50%). The role of depression in the pathogenesis of AD (independent, prodromal symptom, factor of risk) still must be defined. Data on family history of depression suggest that AD could act as stimulus triggering depression from a basis of a genetic vulnerability. From a biological point of view the onset of depression could derive from an unbalance between cholinergic and noradrenergic systems. Psychological understanding sees depression as a reaction of mourning for the cognitive deficit. Current diagnostic instruments validated on patients with AD constitute a good aid for the clinician and the researcher. The identification of depression coexisting with AD is difficult, in absence of clear affective symptoms, since the cognitive, psychomotor and vegetative symptoms belong both to depression and to AD. The affective disorders most frequently reported are major depression and dysthymia. The use of antidepressant drugs with the lowest anticholinergic profile is strongly recommended. Good results have been obtained also using various psychoterapeutic interventions adapted for dementia sufferers. Conclusions – The current scientific debate is based on information still limited and sparse. Future analyses should consider a better definition of the hypotheses related to psychopathology in AD, a standardised definition of cases and selection procedures and a prospective longitudinal design.

Objective – To evaluate the prevalence of dementia among persons born in the year 1930 or before, who were living in Granarolo, Ravenna province, on December 31, 1991. Design – Population study, carried out in two phases: in the first was phase all persons were administered two screening tests for dementia. In the second phase, persons who screened positive underwent detailed clinical and cognitive assessments. Main outcome measures – The Mini Mental State Examination (MMSE) and the Global Deterioration Scale (GDS) were administered as screening tests. In the second phase the screened-positive subjects underwent a general and neurological examination, and a detailed neuropsychological assessment. Results – Of the 557 participants, 56 were clinically diagnosed as demented. Twenty-nine persons were diagnosed as affected by Alzheimer's disease (AD) and 14 patients by vascular dementia (VaD). The crude prevalence ratios for dementia were 9.1% (95% C.I.= 5.29−12.89) for men and 12.7 % (95% C.I.= 8.84−16.6) for women. The prevalence of all dementias, as well as AD, increased steeply every five years of age for both men and women up to 90 years of age. Women had higher prevalence of all dementias and AD than men, more evident in the advanced ages. Conclusions – Our findings are in agreement with similar studies carried out in European populations, showing that prevalence of dementia increases with increasing age. If we consider that in Italy the oldest (those 80 years and older) are the fastest growing part of the elderly population, we can expect that dementia will be a major emerging public health problem, as it is one of the most common diseases in the very elderly and a major cause of disability and mortality.

Objective – This paper reviews 28 studies on the epidemiology of homicide committed by mentally disordered people, taken from recent international academic literature. Methods – The studies included were identified as part of a wider systematic review of the epidemiology of offending combined with mental disorder. The main databases searched were Embase, Medline, HealthStar, Psyclit, Mental Health Abstracts, Applied Social Sciences Index and Abstracts, and Criminology Penology and Police Science Abstracts. A comprehensive search was made for studies published since 1990, supplemented with key studies from the 1980s identified through citation tracing and personal contacts. Results – A summary is given in tabular form of the content and quality of each study. There is then discussion of the studies in eight categories: descriptive studies, studies of trends, comparative studies amongst homicide offenders, amongst prisoners and including general populations, studies of homicide of relatives, follow-up studies, and studies of recidivism. Conclusions – There is an association of homicide with mental disorder, most particularly with certain manifestations of schizophrenia, antisocial personality disorder and drug or alcohol abuse. However, the quality of epidemiological research in this area is not adequate to answer key questions, and prediction of potential for homicide remains elusive. Further research is needed.